Quality Forum 2013 BC Provincial Lean Network Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1: Leading the Transfer of Care for Cardiac Patients from Cardiac OR to Pediatric Intensive Care Unit (Session E9)

Tracie Northway, Manager, Strategic Implementation, BC Children’s & Sunny

Hill Health Centre Barb Fitzsimmons, Senior Vice President, BC Children’s Hospital & Sunny Hill

Health Centre

Objective

• The aim of this initiative was to streamline & standardize a safe admission and handover process of cardiac patients from the Operating Room to the Paediatric Intensive Care Unit.

Background

Background • Historically, post-op cardiac

surgery patients unstable • Identified need • Largest post-op group • Cluster/flock care • Chaos • No clear communication • Missed critical information • Delays in care • Previous improvement attempts

had failed

http://img69.imageshack.us/img69/4634/chaosfieldhp0.jpg

Current State

4.2

2.8

1.5 1.5 1.2

1.3

0.7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Role crossover Tangledequipment/lines

Supplies not whereneeded

Increasedunexplained staff

Waiting for people Deviations from"norm"

"Presence" athandover

Aver

age

Defe

cts/

Hand

over

Defect Category (n=# of occurences over 6 handovers)

Cardiac OR to PICU Handover of Care: Pre-Kaizen Average Defects per Handover

(6 Handovers)

• Team selection PICU: staff nurse; charge nurse; quality & safety

lead (lead) Cardiac OR: anaesthesia assistant, anaesthetist;

clinical resource nurse; perfusionist External: imPROVE facilitator (sub-lead); vice

president; corporate executive assistant Content experts: PICU physicians; cardiac

surgeons; respiratory therapist; professional practice leaders

Solution

Solution

Set and met 4 targets: 1. Determine characteristics of a safe patient

handover from OR4 to PICU 2. Define standard work (process,

roles and responsibilities) for a safe patient handover

3. Develop tools to guide & support standard work

4. Test standard work tools

Solution Activity Day 1 Day 2 Day 3 Day 4 Day 5

Orientation to Lean principles

Team goal setting for the week

Define “standard work” for Cardiac OR to PICU safe handover of care

Development of Handover Tool

Bed Set-up (crib) defined, prototyped & tested on admission

Protocol for handover drafted

Education for OR #4 Team and PICU staff admitting CVS Patient

Digital recording of admission

Debriefing with OR & PICU staff about admission

Review of debriefing notes

Areas for improvement discussed

Strategies brainstormed

Handover Tool (Checklist) revised & tested

Protocol for handover revised & tested

Admission recording reviewed, standard work documented & defects counted

Daily “report out” to Sensei Iwata

“Stamping” of project work by Sensei Iwata

Practice for “Final Report Out”

Team “Final Report Out” to Sensei Iwata, other teams, sponsors and administration

Creation of sustainment plan Ongoing

Results of Kaizen

4.2

2.8

1.5 1.5

1.2 1.3

0.7

0.0

0.3

1.0

0.0 0.0 0.0 0.0 0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Aver

age

Defe

cts/

Hand

over

Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW Average Defects per Handover

Pre Kaizen (6Handovers)

Kaizen Wk (3Handovers)

Results of Kaizen

Results of Kaizen (3 Years Post)

4.2

2.8

1.5 1.5

1.2 1.3

0.7

0.0

0.3

1.0

0.0 0.0 0.0 0.0 0.0 0.0 0.1

0.0 0.0 0.0 0.2

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Role crossover Tangledequipment/lines

Supplies notwhere needed

Increasedunexplained staff

Waiting forpeople

Deviations from"norm"

"Presence" athandover

Aver

age

Defe

cts p

er H

ando

ver

Defect Category

Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW to 2 Years Post Kaizen

Pre Kaizen (6 Handovers)

Kaizen Wk (3 Handovers)

2 yrs Post-Kaizen (19 Handovers)

Next Steps/ Sustaining the Gains

• Adopted for spinal surgery handover • Plans for spread to 100% of surgical teams for

2013-2014 • Agreement from Surgical Council • Improvement planning group meeting

Lessons Learned

• A pull for change is easier to make happen

• Right people on the team • Value of senior leader on team • Create a process dependent protocol;

not person dependent • Don’t reinvent the wheel • Live quality improvement cycle; be

responsive