Healthcare is one of the most people intensive service industries that there is today. No different from other service based industries – employees influence customer satisfaction. More importantly, as a healthcare institution built around delivering care to patients, employees -- and nurses most specifically -- take on a critical role in organizational performance and patient satisfaction.
Healthcare institutions are the hub of many crucial touch-points in a patient’s wellness journey in which nurses play a vital role. Consider an episode of hospitalization. The patient, as a consumer of services, is in the hospital for an extended period of time. During this time, numerous procedures and interventions are performed such as surgery, medication administration, physical therapy, venipuncture, etc. Although these appear to be a set of distinct tasks, below the surface, all the activities are coordinated through the patient and nurse relationship.
During an inpatient stay, patients can experience many emotions and sensations such as pain, fear, doubt, and frustration. Nurses serve as the front-line advocate, coach, and counselor for patients. This enriches the relationship over time. A patient’s perception of care is also closely aligned with a sense of safety and trust; expectations often associated with nursing oversight of care. Patients regard their care experience as “safe” when nurses provide personalized, predictable, well-coordinated care.
These care attributes are commonly challenged by frequent interruptions, mismatched team dynamics, environmental factors, and fragmented IT (information technology) systems, all of which can conspire to pull the nurse away from the bedside. Today’s care-delivery model, and our patients, both demand we bring nurses back to the bedside to provide innovative, personal, and exceptional care. We accomplish this by driving the value proposition toward workflow efficiency, redefining team member roles, and reducing waste.
Understanding a day in the life of a nurse
In 2011, Lancaster General Hospital conducted a nurse satisfaction survey in which nearly 50 percent of nurses responded that they did not have sufficient time for patient care. In addition, respondents perceived that the important things were not being done all of the time. The nurse satisfaction survey results combined with our drop in patient satisfaction scores prompted nursing leadership to act quickly. The demands and pace in acute care have accelerated and nurses were increasingly feeling as though their ability to provide that special touch had diminished.
Lean principles were used to evaluate nursing workflow through direct observation. The exercise identified the following barriers to care delivery.
Hallway clutter and lack of dedicated storage spots for equipment with "everything being everywhere"
- Extensive travel between patient rooms, supply rooms, and equipment areas
- Significant chaos and delays during key handover times: Admission, Discharge and Shift Hand-offs
- Task duplication and variation in execution among team
Validation from nurses came in a similar form. In our interviews with nurses, we came across similar themes. They said, among other things:
- "Documentation of assessment takes 'too much' time"
- "I am unable to find supplies 'most of the time'"
- "I am 'always' looking for the chart."
A simple, yet powerful Lean tool - 5S (Sort, Set in Order, Shine, Standardize and Sustain) - was used in the high-volume, multiuser locations to standardize the working environment and hardwire expectations for common team workflows or activities.
It is easy to see the amount of tasks that draw nurses away from the patient. From finding a pillow to documenting medication administration, a nurse’s day is inundated with tasks so varied and intricately meshed, that it is no easy task to delineate the “must dos” and the “good to dos.” We needed a data-driven approach to helping quantify these observations. This requirement would not only help prioritize efforts, but also quantify impact. This led to an effort anchored around making nursing more patient focused.
Getting to the root of the problem
While our observations validate the need to bring nursing back to the bedside, we realized that it was imperative to anchor the initiative. For this, among other things, we needed to;
- Define success measures
- Define and select a pilot unit
- Create a cross functional problem solving group
After several weeks of intense data collection, we realized that over a 24 hour period, nurses on average spent just 24 percent of their day providing nursing care, with the rest being lost to administrative duties or other non-value added activities. It was imperative to start with eradicating non value added activities. For clear motivation, we made it our goal to increase value added activity by 50%.
The leadership across Performance Improvement realized that the framework that would help do this was Lean. Lean as a philosophy empowers people who are at the front line of performing tasks. The concept of a Kaizen or “continuous improvement” involves bringing together a cross-functional group to solve for problems across user groups. It also allows flexibility to try solutions that work for teams. It does this by allowing teams to brainstorm and then trial solutions, or trystorm. The team’s focus was to look at implementing Lean methodologies to decrease waste and improve efficiency, and to solve for non-value added elements that truly need to be eradicated for more time with patients. As observations were completed and nursing input received, common trends were discovered. They included frequent interruptions when nurses were with patients, wasted movement both among patients and those looking for supplies, and high variability in time to complete tasks among nurses. The team prioritized these findings and began to form small kaizen sub-teams to solve for one problem at a time.
As the efforts led to fruition, the solution clusters interestingly started to mirror Relationship-Based Care (RBC), the foundation for Lancaster General’s nursing model of care and shared governance. Relationship-based care is a transformational care approach built on three important pillars: Care of Self, Care of Colleague and Care of Patient. To strengthen the concept of care of self, nurses need to be empowered to make decisions.
Take for example the flexibility to complete vital signs – allowing nurses to make the decision on how often to complete them in the clinical setting, based on the patient’s condition is true empowerment or Care of Patient. Another correlate to RBC principles is the reduction in phone calls to RNs. Direct calls to nurse frequently interrupt care. Our pilot unit created a unit clerkdriven mechanism to filter and resolve calls originally directed to the primary nurse. The new practice more than halved call volume.
Spreading awareness and value
The benefits realized on the pilot unit compelled Lancaster General’s leadership team to deploy and standardize the new team workflows across the hospital. Standardization is a powerful efficiency mechanism – imagine knowing where standard supplies were kept on every unit and always being able to find a fully charged infusion pump when you need one. These are rewards that benefit nursing teams tremendously.
Numerous kaizens benefitting the pilot unit were taken up for an enterprise-wide launch. The synergistic effect and careful sequencing of these simple improvements aimed to increase patient and staff satisfaction and improve outcomes by enhancing patient throughput, and intra-departmental coordination. The endgame: reduce length of stay and readmissions.
Geographical pod configuration of patients is one good example. Although this pod concept is not new to inpatient floors, the success of making the model work is to relentlessly trystorm and build a powerful sustain plan. Giving nurses an allocated set of beds is hardly any different from rationing a piece of real estate. What makes it work and contribute to bigger efficiencies is to have a structure to podding itself – reducing nursing movement, allowing for good visibility of patients, enabling work-load balance among pods.
Podding coupled with an RN shift facilitator, who without an assignment, is tasked with monitoring hand-offs created immediate “at-the-elbow” support for the team. Admissions and discharges are the most demanding times in patient throughput. Needless to say, since these are the times that form the basis for the patients journey to recuperation and wellness thereafter, these interfaces need to allow for undivided attention from nurses.
Back to bedside: The journey
Caring and compassionate care for patients comes naturally to nurses. In contrast, performance improvement and process redesign are not skills all nurses possess. Nurses equipped with the right tools and resources can creatively overcome major obstacles to quality outcomes. Empowered staff engages more effectively and are in turn, happier in their work thus creating a positive, healing patient care environment. Utilizing the unit based shared governance supported by RBC principles, staff on the pilot floor demonstrated their strong commitment to change and quality by engaging in 90 percent of the kaizen events. The kaizen teams focused not only on improvements benefiting team workflow and staff satisfaction but also strategies to increase patient satisfaction. Real success was demonstrated through a significant increase in direct patient care in an RN’s day, from 20 to 30 percent.
This paper was authored by Lanyce Horn, Executive Director, Ortho & Neuroscience, and Stacey King, Director of Nursing, Lancaster General Hospital and Raj Matthew, Genpact Reengineering lead for Healthcare.
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