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Adaptive Design The Path to Ideal Care. Debra Shriver, MSN, RN Chief Nurse Executive Trinity Regional Medical Center, Fort Dodge April 2010. Objectives for the day. Review the IHS Vision Provide overview for Adaptive Design

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Adaptive design the path to ideal care

Adaptive DesignThe Path to Ideal Care

Debra Shriver, MSN, RN

Chief Nurse Executive

Trinity Regional Medical Center, Fort Dodge

April 2010


Objectives for the day
Objectives for the day

  • Review the IHS Vision

  • Provide overview for Adaptive Design

  • Share examples of Adaptive Design and the scientific methodology to solve problems (A3)

  • Outcome measures at various affiliates

  • Describe challenges, lessons learned, and integration of core processes into an EMR.


Goal ideal care that achieves best outcome for every patient every time
GOAL:Ideal care that achieves best outcome for every patient every time

  • Patient Centered

  • Based on best practice/evidenced based

  • Efficient/adds value/enhances the patient experience

  • Electronic medical record enables care

  • Professional practices nurtured/effective work teams


Goals not an all inclusive list
GOALS (not an all inclusive list)

  • 95% of patients willing to recommend

  • 0 codes on med/surg units

  • Less than 5% readmissions within 30 days

  • Achieve 90% or above in all quality measures (HF, MI, Pneumonia, Infection Preventions, etc.)

  • No patients fall

  • No skin breakdown

  • Increase caregiver time at the bedside to 60-70%


Adaptive Design is an improvement methodology developed by John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

John Kenagy, 2009


Adaptive design
Adaptive Design: John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Toyota Production System

    • How people work and manage

    • How they think about their work

    • How they learn and work together to improve


What is adaptive design
What is Adaptive Design? John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • The foundation of the work is observation

    • Honors the work of the front line staff

    • Allows observer to ‘see’ the whole picture—eliminates assumptions

    • Detailed observations provide opportunities for problem solving

  • All the improvement work is based on the point of view of the patient

  • Creates a culture of improvement that uses the creativity, knowledge and problem solving ability of frontline staff to solve problems whenever care is not ideal.


Problem solving
Problem Solving John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • First order

    • Solving the problem for this patient and this clinician at this time (work around)

  • Second order

    • Get at root cause and solve the problem for future patients and clinicians


Adaptive design sets direction ideal patient care
Adaptive Design sets Direction: John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.Ideal Patient Care

“My family and I get what we want and need, safely and without waste and without having to wait.”


Rules of adaptive design
Rules of Adaptive Design John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Strive for Ideal Patient Care

    • Ideal Patient Care is a test to see if we are delivering the best outcome for every patient, every time. It can be answered with a yes or no. Did the patient get what he wanted, and needed safely without waste and/or having to wait?


Rules of adaptive design1
Rules of Adaptive Design John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • There are 4 rules in Adaptive Design that are used to assist us with achieving ideal care

    • Rules 1-3 guide the work that is being done

    • Rule 4 guides us through problem-solving


Rule 1 how people work activities
Rule 1—How People Work-Activities John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • All work shall be highly specified as to content, sequence, timing, and outcome.

  • If work is highly specified, it does not allow variation in the way employees do their work.

  • Too much variation in a work process can lead to

    • Poorer quality

    • Lower productivity

    • Higher costs

    • Hinders learning and improvement in the organization because the variations hide the link between how the work is done and the results.


Activity
ACTIVITY John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Rule 2 how people connect connections
Rule 2- How People Connect-Connections John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses.

  • The connection should not have any gray areas.

  • The connection should provide who, what, when, where, and how.

  • When a person needs assistance, there is no confusion over who will provide it, how the help will be triggered, and what services will be delivered. (Help chain)

  • This rule encourages employees to ask for help at once.


Rule 3 how the production line is constructed pathways
Rule 3-How the Production Line Is Constructed-Pathways John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Every product or service flows along a simple, specified path

  • There should not be any deviation from the pathway

    • No forks or loops

    • Care and services do not flow to anyone, but to a specified person or equipment

  • The care we provide is a series of different pathways (services):

    • Admission

    • Medication Administration

    • Discharge

  • Each pathway has several different activities (Rule 1) and connections (Rule 2)

  • Those not connected to the pathway do not need to be there (Eliminate wastes and reduces repetition)


Rule 4 how to improve a3 problem solving
Rule 4-How to Improve- John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.A3 Problem-solving

  • Any improvement to production activities, to connections between workers or machines, or to pathways must be made in accordance with the scientific method, under the guidance of a coach, and at the lowest possible organizational level.

  • Encourages management to mentor frontline staff and be facilitators

  • Develops staff members into a community of learners who participate in the problem solving

  • Problems, as signaled by staff, are solved using a scientific method

    • Tackles specific problems or failures rather than generalize or assume the issue.

    • The countermeasures are solutions developed based on the particular cause.


What is the adaptive design process
What is the Adaptive Design process? John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Observations of the current state

  • Look for “signals” when patient care is not ideal

  • Problem-solve using a scientific method (A3s)

  • Implement and Test Countermeasures quickly

  • Continue with Countermeasure, until failure is signaled by frontline staff


Adaptive design transformation
Adaptive Design Transformation John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Is a disciplined approach

  • Creates a culture change in how to solve problems

    • Every solution is a “test” and we expect it will fail---but we will learn more about the issue and come closer to the ideal

    • Every employee becomes a problem solver

  • Removal of barriers of ideal patient care

    • No “work-a-rounds”

    • No communication gaps

    • Eliminates repetition and redundancies

  • Increase quality

    • Increases nurse time on patient care

    • Increases patient satisfaction

    • Increases employee satisfaction


Allen memorial hospital
Allen Memorial Hospital John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Tami Jones, RN, MSN

    • Clinical Director of Med/Surg and Nursing Innovation

  • Christa Lerch, RN, BSN

    • Staff Nurse on 4 Ortho


Frontline design at allen where we have been
Frontline Design at Allen-Where we have been… John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • 4 Ortho

    • Elisia Heidt-Penrod, RN, BSN

  • 3 Medical

    • Andrea Johnson, RN, BSN

  • Pharmacy

    • Tim Schmidt R. Ph and Jeff Martin R. Ph

  • 3 Surgical

    • Rita Borrett, RN, BSN

  • 4 NET

    • Carmen Mundt, RN, BSN

  • Inpatient Therapy

    • Molly Ehrig, OTR/L

  • Distribution

    • Kari Beschorner


Frontline design at allen where we are
Frontline Design at Allen—Where we are… John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Emergency Department

    • Mike Tiedt, RN, BSN

  • OR

    • Jenni Friedley RN, BSN,

    • Missy Michaelson, RN, BSN

  • PACU

    • Dana Clasen, RN, BSN

  • Ambulatory

    • Vonice Hoffman, RN

  • Sterile Processing

    • Janine Reuter, RN

  • Ambulatory Surgery Center

    • Kim Prinsen RN, BSN

    • Jenni Goos, RN

    • Joe Randall, RN


Frontline design at allen where we are going
Frontline Design at Allen Where we are going… John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

Everywhere!!!!


Frontline design at allen
Frontline Design at Allen John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Teachers

    • Tami Jones, RN, MSN

    • Shari King, MPT

    • Jessica Lovrien, RN, MSN

    • Lynne Blythe, MBA

    • Denise Schult

    • Chris Clayton, PharmD, MBA

    • Marty Colwell, MA


Allen a3 detox on 4t
Allen A3: Detox on 4T John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Root cause
Root Cause John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Target condition
Target Condition John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Countermeasures
Countermeasures John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Allen outcome measure
Allen Outcome Measure John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • We are solving problems throughout the organization.

  • 376 A3’s in test as of April 1st!


Allen what has this work meant to me as a staff rn
Allen—What has this work meant to me as a staff RN? John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • Identifying 1st order problem solving and using 2nd order to solve the problems so I can spend time with patients

  • Decreased frustration with other department

    • We get to learn about and honor their work

  • Gratifying to get to the root cause and really solve problems


Blueprint unit

Blueprint Unit John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

Trinity Regional

Medical Center

Fort Dodge


2 north
2 North John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

  • 37 Bed Medical / Telemetry Unit

  • Blueprint Team

    • Staci Olson, RN Nurse Manager

    • Sue Niemeyer, RN Clinical Educator

    • Sara Ladlie, RN Staff Nurse (days)

    • Lori Hoover, RN Charge Nurse

    • Jenna Matton, RN Staff Nurse (nights)

    • Kim Bennett, RN Staff Nurse (days)

    • Carol Archer, PCT (nights)


Time savings example
Time Savings Example John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

If one RN spends 5 minutes looking for an isolation gown while the patient is waiting to go to the bathroom and this happens to six nurses in 24 hours that would equal 184 hours of wait time for the patient and wasted time for the RN

What could you do for your patients with 184 hours in a year?


Cost savings example
Cost Savings Example John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

If we have 100 A3s that save 30 minutes (gown example) in 24 hours for the RN = 184 hours

184 (hours) x 100 (A3s)

=

18,400 hours / year

=

8.8 FTEs or 9.7 FT (72 hr)

=

$20.00 x 9.7

=

$194.00/hour x 72 hrs / pay period

=

$13,968 x 26

=

$363,168 / year


Outcome measures
Outcome Measures John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


Outcome measures1
Outcome Measures John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.


What this work has meant
What this work has meant John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

Improvement in our work

Saving time

Making things run more smoothly

Less running around

Problems don’t occur again

Reduction in waste

Changed the focus from the nurse to the patient—hear more “what’s best for the patient”

All about the patient; patient centered care

Staff work together as a team


What impact has this had
What impact has this had? John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

Changes in our interactions with other departments

Staff involvement with solving the problems that are signaled

Increase quality time with the patient

Cost savings, reducing waste


The finley hospital adaptive design information for leadership symposium
The Finley Hospital Adaptive Design Information for Leadership Symposium

  • Chris Wilson, RN MSN- Director of 4 Med/Surg and Inpatient Acute Rehab Unit

  • Sarah Bader, RN BSN, Staff nurse 5 Med/Surg and Clinical Adjunct Instructor for Clarke College Nursing School


Our two 20 bed med/surg units plus the 21 Leadership Symposiumbed 5 North Med/Surg/Peds. units are engaged in adaptive design process. Blue Print team members include:

  • Diana Batchelor, RN MSN, CNO Finley

  • Teresa Neal, RN MS – Six Sigma Black Belt/ Blue Print lead facilitator

  • Pat Lehmkuhl, RN MSN- PI Coordinator and Blue Print team facilitator

  • Chris Wilson, RN MSN, Director 4 M/S

  • Cheryl Haggerty, RN, MSN, Director 5 M/S and 5 North

  • Londie Brauer, RN BSN, Educator 5 M/S and Rehab

  • Dee Maahs, RN, BSN, Educator 4 M/S

  • Sarah Bader, RN BSN, Staff RN 5 M/S

  • Melissa Shannon, RN, BSN Staff RN 5 M/S

  • Julie Beyer, RN, Charge RN 4 M/S


A3’s Leadership Symposium


Outcome measures that we are proud of
Outcome Measures that we are proud of: Leadership Symposium

  • ● Redesigned the supply process on both floors to

  • apply LEAN concepts and to ensure that supplies

  • are readily available for the nurse so that the patient

  • does not wait for care. Since redesign we have

  • seen a significant drop in the number of calls to

  • Purchasing for missing items.


Outcome measures that we are proud of1
Outcome Measures that we are proud of: Leadership Symposium

  • ● We identified a significant issue with IV push for large doses of Lasix. Blue Print team worked with pharmacy to develop process to piggy back medication so that the nurse is free to monitor the infusion and attend to other needs instead of having to remain in the patient room for a long period of time pushing the medication.

  • ● Since beginning Blue Print in October 2009 we have completed 55 A3’s for 2009 and 44 A3’s are in process or completed as of April 2010.


Staff Nurse Perspective: What has this work meant to you and/or your unit? What impact has it had?

  • ● Working with Blue print has been exciting because it has given us the opportunity to really look at ideal care and what that means to the patient. I have enjoyed developing the definition of ideal care and working with the staff and the patients to identify and work signals. We have learned to think differently about problems and the process has opened our eyes to recognizing “work arounds” as problems that we can fix.


Iowa health des moines
Iowa Health Des Moines and/or your unit? What impact has it had?

N3 Blueprint Unit


Ih dm n3 blueprint unit
IH-DM N3 Blueprint Unit and/or your unit? What impact has it had?

  • 24 bed Cardiovascular Unit

    6.7 Admits per day

    5.8 Discharges per day

    32% Patient Turnover per day

    58 Staff on Unit

  • Blueprint Team Members

    Jennifer Early (Director of Adult Behavioral Services)

    Pat Busick (Quality Improvement Coordinator)

    Sharon Henry, RN, BSN

    Toby Riddle, RN, BSN, Unit Based Educator

    Kathy Quick, Nurse Manager


Ih dm ideal care
IH-DM Ideal Care and/or your unit? What impact has it had?

The patient and family will say, “I receive the care I need and want safely, on time, with respect and compassion”.


Senior leader executive director experience
Senior Leader/Executive Director Experience and/or your unit? What impact has it had?

  • Purpose:

  • - To learn and honor the work of the

  • staff in a 2 hour experience

  • - Assist leaders to identify with us the

  • barriers in providing ideal care


Reflections
Reflections and/or your unit? What impact has it had?

  • Senior Leaders

  • - Quotes

  • Blueprint Team

  • - Culture Change


Last but not least
Last but not least: and/or your unit? What impact has it had?

  • Adaptive design guides work in identifying

    steps in core processes.

    1. Admit (Jan.)

    2. Discharge (Feb.)

    3. Medication administration/reconciliation (Mar.)

    4. Care of the Patient (April)

    5. Orders (pending)

  • In terms of content-sequence-timing i.e, admit

     hx present illness

     Patient profile (ht, wt, allergies)

     Med Rec

     Physical Assessment

     Screenings

     Advanced Directive

     Documentation of immediate – non immediate care


Last but not least1
Last but not least: and/or your unit? What impact has it had?

  • Timing

    1. Direct admit: 60 minutes or less

    2. ED admit → nursing unit – 30 minutes

    uninterrupted

  • IT Enabled: A few examples:

    1. Order sets automatically generated from data

    entered

    2. CPOE

    3. Work list for physicians/eliminate “sticky” notes

    4. Template data from previous admission, ED,

    clinics, pharmacies

    5. Work list of incomplete handoffs.

    6. Single sign on.


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