Michigan Medicine

Determining Off-Unit Peritoneal Dialysis Workload of 6B Charge Nurses

IOE 481/20W2-Final Report

Submitted To:

John Swirple, Clinical Nursing Director, Acute Care Medicine UnitWinnie Wood, Clinical Nurse Specialist, Acute Care Medicine Unit

Sandra Kendziora, Clinical Nurse Supervisor, Acute Care Medicine UnitOlivia DeTroyer-Cooley, Continuous Improvement Engineer, Quality Department, Michigan

MedicineJakob Kiel-Locey, Continuous Improvement Fellow, Quality Department, Michigan Medicine

David Hyatt, Senior Continuous Improvement Specialist, Quality Department, Michigan Medicine

Mary Duck, Admin Manager Continuous Improvement, Quality Department, Michigan Medicine

Submitted By:Jeremy Young, Industrial and Operations Engineering Student

Gabriel Johnson, Industrial and Operations Engineering StudentNikhil Patel, Industrial and Operations Engineering StudentRabi Osagie, Industrial and Operations Engineering Student

Date Submitted:April 21, 2020

Table of Contents

Executive Summary 3Background 3Methodology and Findings 3Recommendations 5

Introduction 6

Background and Key Issues 6

Design Process 7Goals and Objectives 7Design Constraints and Standards 8Design Tasks/Deliverables 8Design Criteria 9

Data Collection and Analysis Methods 9Charge Nurse Self-Collection 10In-person Team Observations 12Data Analysis 12

Literature Search 14

Alternative Solutions 15

Recommendations 15Expected Impact 16

Future IOE 481 Project Group Possibilities 17

References 18

Annotated Bibliography 18

Appendix 1: Constraints and Standards Matrix for 6B Charge Nurse Off-Unit Peritoneal Dialysis Work-Load 19

Appendix 2: Pugh Matrix for 6B Charge Nurse Off-Unit Peritoneal Dialysis Work-Load 20

Appendix 3: Updated Gantt Chart 21

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List of Tables and Figures

Table 1: Summary of Historical Data of Self-Collection 10

Figure 1: Task B and Task E are significant 11

Table 2: 95% and 99% Confidence Intervals for Feasible Tasks 12

Figure 2: Finding a replacement nurse significantly impacts the NVA percentage 13

Figure 3: Standardizing the Process of Finding a Replacement Nurse 16

reduces NVA by 22.83%

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Executive SummaryCharge nurses in Unit 6B are responsible for administering peritoneal dialysis for patients all around the University of Michigan Hospital. During the evening shift, the charge nurse must set up dialysis machines as well as attend to any alerts that occur during the evening. In order to do this the nurse must sometimes leave their unit, visiting peritoneal dialysis patients in other regions of Michigan Medicine. Traveling throughout the hospital system takes time, and leaves the remaining evening 6B nurses without leadership in the unit. The Clinical Nursing Director, Clinical Nursing Specialist, and Clinical Nurse Supervisor asked the team to quantify the amount of time 6B night shift charge nurses spend attending to peritoneal dialysis patients off the unit, and determine if changes need to be made to the current staffing model. This evaluation consisted of analyzing the current process for peritoneal dialysis setup, evaluating alternative solutions, and developing recommendations for improving the process.

After examining the current situation, the team developed different options for streamlining the peritoneal dialysis process and reducing unnecessary steps within the process while adding more structure to Unit 6B when the charge nurse is off-site.

BackgroundPeritoneal dialysis treatments involve attaching a cycler machine to the patient’s abdomen and cycling dialysis fluid into their body. During the P shift, which lasts from 7 PM - 7:30 AM, the unit 6B charge nurse must set up peritoneal dialysis for patients on and off the unit. Peritoneal dialysis is one of many different tasks performed by the charge nurse. The charge nurse also assists other 6B nurses with patient assignments, cares for their own patient assignments, documents patient treatment, and handles calls and new arrivals.

Methodology and FindingsThe team performed five tasks to optimize and more thoroughly understand the workload of the peritoneal dialysis process:

● Observed and interviewed nurses on the 6B staff. The team gained a strong understanding of the charge nurse’s roles, and some basic knowledge on the workings of the rest of the 6B unit. The team wanted to formulate their own ideas about what could be improved, while also listening to any suggestions of the staff.

● Performed a literature search detailing the relationship between nurse staffing and adverse patient effects. Reducing the amount of patients for each nurse led to much better care overall. When nurses were overloaded with work, they primarily skipped “reporting and all paperwork involved with tracking measures”. This greatly hurts the possible improvement of the 6B unit.

● Completed a data analysis based on our direct observations and the self-collection the nurses undertook. We computed confidence intervals for each of the different tasks the charge nurses performed to understand the variability and length of each task.

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● Developed recommendations for improving the peritoneal dialysis process and charge nurse workload.

The team evaluated the data compiled through a literature search, interviews, historical data and on-site observations to draw valuable insights into the workflow and processes in unit 6B. The main findings that significantly impacted the recommendations and alternative solutions are described as follows:

● The charge nurses are overloaded with responsibilities which causes the busier hours to be difficult to manage. The scope of tasks they are responsible for seems so wide that it causes the roles of all other nurses and techs to be a gray area.

● From on-site observations, it was apparent that finding a nurse in 6B to cover for the charge nurse while they are off-unit is a source of various types of waste (extra-processing, waiting, and unused talent). The charge nurse on duty spent excess time trying to locate and communicate with a substitute nurse to lead the unit while the charge nurse was off-unit.

● The process of gathering the proper supplies based on nephrologist’s orders isn’t standardized. At times, the prior shift will set up the supplies, while at other times the current shift will prepare those supplies at the time of tending to off-unit PD patients. This is a “kind gesture” but isn’t particularly helpful and of course not necessary as one of the nurses pointed out.This produces over-processing wastes, as addressed during interviews, because preparing the nephrologist’s orders in the prior shift doesn’t save time for the next shift as they will have to carefully review the contents again for safety reasons.

● From historical data, there is a significant time spent with high variability communicating with the nephrologist.

● The role of clerk in 6B is broad as well, but deals primarily in processing orders and triaging other communications for the unit. Utilizing the charge nurse resource to manually log stockroom inventory presents unutilized talent; the charge nurses could be assisting others.

RecommendationsThe findings from the team’s research during this project are variable and widely-scoped, so our recommendations include conclusions and alternative solutions. There are a few conclusions that the team explored to improve process efficiency and more clearly define the roles and responsibilities of the nurses. There is a need for: (1) a standardized process in scheduling, locating and communicating with a substitute on-unit charge nurse, (2) a formal process for preparing the equipment and supplies prior to travelling to off-unit patients, and (3) a shift in responsibilities for maintaining and manually logging the stockroom inventory. These recommendations stem from the project’s design requirements, constraints, and standards.

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The first recommendation is crucial because it reduces numerous forms of waste. Currently the charge nurse must choose, physically look for, and assign the informal role of substitute on-site charge nurse. Additionally, the means of communication include, pager and cell-phone. The first recommendation within this larger issue is to standardize the methods of communication to include assigning a specific phone to the charge nurse and programming all other work phones to be notified that it is the charge nurse texting or calling. In reality this can be something as simple as a specific ringtone or pager beep for the charge nurse contact. Another recommendation under this topic involves the scheduling process of the substitute charge nurse. This would be clearly labelled on the schedule ahead of time. It would be beneficial to all nurses on the shift to know that the substitute is nurse “X” while the charge nurse is off-unit. This takes the ambiguity of who will be the leading nurse in the case that the charge nurse is extensively working off-unit.

The second recommendation stems from an overprocessing waste found during observations and interviews. The current process involves the charge nurse receiving nephrologist order’s and preparing those supplies when they are ready to physically travel to off-unit patients. The overprocessing occurs when the prior shift prepares these supplies ahead of time for the next shift (which occurs with notable consistency). As mentioned in the findings, this doesn’t save time because the charge nurse is still responsible for validating the supplies that were set aside are consistent with all of the nephrologist’s orders.

Lastly, our team recommends that there be an overall reassessment of roles and responsibilities within the unit. This suggestion was inspired from watching charge nurses take inventory of the stockroom when they had a long list of other tasks to complete. The team suggests, for example, that the clerk might be a great role to complete the stockroom management, considering their current responsibility of placing supply orders.

Overall, we recommend that this project receives follow-up work. Given the COVID-19 outbreak, hospital and school guidelines prevented further data collection and observations to take place. For the unit, it is crucial to continue nurse self-collected time data when resources permit. For the follow-up student team, beginning time studies and diving deeper into the roles and responsibilities defined for the unit will be extremely beneficial.

IntroductionUnit 6B is the Acute Care Medicine Unit located on floor 6 of University of Michigan’s University Hospital. Charge nurses in 6B are responsible for running peritoneal dialysis (PD) for patients on and off the unit. Peritoneal dialysis treatment involves attaching a cycler machine to a patient’s abdomen, and cycling dialysis fluid into their body. It is typically performed over the course of the night for about 6-8 hours, typically beginning at 9 PM and concluding around 5 AM. While peritoneal dialysis patients are typically admitted to units in 6B, they may also be

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admitted to other regions of the hospital. When this is the case, the charge nurse may have to leave their unit and travel to other regions of the University of Michigan Hospital System (UMHS). The purpose of this project was to quantify the amount of time P shift 6B charge nurses spend attending to peritoneal dialysis patients off the unit, and to determine if a charge nurse dedicated to off-unit peritoneal dialysis work should be hired. The team collected both qualitative and quantitative data by observing the process to understand the current workflow, interviewing the charge nurses, and conducting time studies to identify the length of time spent attending to dialysis machines. Using this data, the team created a current state map to better understand the inefficiencies in the process. Finally, after analyzing the quantitative data and performing a literature search, the team developed a future state map and recommendations for improving the peritoneal dialysis management process. The team focused on this project for 3 months, from January 2020 to April 2020. The purpose of this document is to lay out the current state of peritoneal dialysis treatment done by the 6B charge nurses and give our possible solutions and recommendations regarding how to improve this process.

Background and Key IssuesThis section explains the background key issues that unit 6B is facing regarding off-unit peritoneal dialysis treatment.Unit 6B has about nine nurses during the day shift, nine during the evening shift, and eight during the night shift. During each of these shifts there is one charge nurse. The charge nurse does not receive patient assignments. Instead they assist the 6B nurses with their patient care responsibilities and, during the night shift, run peritoneal dialysis for patients off and on the unit. Running peritoneal dialysis includes the following steps:

1. Checking MiChart to determine who the patient is, where they are located and how many dialysis bags they require

2. Acquiring the bags dialysis solutions and placing them on a cart3. Traveling to the peritoneal dialysis patient with the cart4. Removing dialysis bags from the cart and attaching the bags to the cycler machine5. Moving to the next patient to set up their cycler machine6. Returning to unit 6B with the cart7. Troubleshooting any alerts from the off-unit dialysis cycler machines8. Disassembling the cycler for each patient when dialysis is complete

Nurses have been asked to self-report how long they spend performing peritoneal dialysis duties, but this data has yet to be verified by an independent source.The key issues driving the need for this project are:

● The need to obtain more detailed data regarding how much time 6B charge nurses spend caring for off-unit patients on peritoneal dialysis

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● The charge nurse must split her time between assisting the 6B evening-shift nurses as well as responding to alerts from peritoneal dialysis patients in other units, leaving the new evening nurses with a lack of leadership

The biggest difficulty that the team overcame to address this problem was collecting accurate time data on the charge nurses. Self-collection can be subject to personal bias, while time studies data that is collected by the team can be influenced merely by the team’s presence in the nurses’ work environment.

Design Process The following sections describe the goals and objectives, design constraints and standards, design tasks and deliverables, and project changes, and requirements or criteria by which the alternative designs will be evaluated and ranked by.

Goals and ObjectivesTo decide possible advancements for the 6B unit, the team needs to:

● Comprehend and evaluate the current state and setting of the 6B nursing unit● Create a set of studies on the processes of the charge nurse inside the nursing unit through

observations

The primary goal is to determine whether or not unit 6B needs another charge nurse for the evening shift. The objective includes accurately depicting how much work is being done by the nurses, and how much of each type of work is being done. Some other objectives concerning information that needs to be collected include gathering how much time the charge nurses are working with each out of unit patient. The intention is to measure the amount of time a charge nurse spends setting up peritoneal dialysis which includes taking the equipment off the cart, setting it up to the patient to start dialysis, and taking the equipment off the patient to end dialysis. Travel time is currently not accounted for by the hospital.

With this information, the team will:● Provide a final report with all of the findings that have been discovered from this project● Create a Value Stream Map for both the current state and future state of the 6B unit

charge nurse off-unit patient care ● Provide conclusions on whether or not another charge nurse is needed● Give recommendations to increase productivity within the 6B nursing unit

We were planning on presenting the clients with a simulation, but due to the spread of COVID-19, the team was forced to halt all time-studies, which would have been used in the development of the simulation.

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Design Constraints and StandardsDesigning a study with moving parts and widely distributed variable wait times induces an array of logistical constraints. One constraint is the walking time from 6B nursing unit to the peritoneal dialysis patients (in various locations throughout UMHS). Decreasing walking time will be difficult to overcome without supplemental or different methods of transport from one section to another section of the hospital system. Additionally, the client mentioned that nurses have extremely long, variable wait times for elevators which is equally hard to overcome. Another design constraint is that only one charge nurse can respond to peritoneal dialysis alerts; two nurses cannot both leave 6B to respond to these alerts. The client insisted that it would not be feasible for the 6B nursing unit to have two charge nurses working at the same time. Another constraint to the scope of the project is that we cannot alter or distribute nurses from other sections of the hospital to and from 6B. We can only improve and change the policies and processes of the 6B nursing ward. As for standards, the team will adhere to HIPAA in protecting patient health information in providing recommendations for the 6B charge nurse off-unit workload. The team also adhered to state and UMHS guidelines in regards to in-person observations during the COVID-19 pandemic, by halting all in-person data collection. The design constraints and standards have been put into a matrix in Appendix 1 to further exemplify their importance.

Design Tasks/DeliverablesThe first deliverable is the direct results of our time studies and observations along with statistical hypothesis tests and prediction methods. We want our clients in Unit 6B to have the raw data for their later use if more validation is needed. We also want them to understand the hypothesis tests, so they can better predict patterns of the number of dialysis patients each day.

We then made a value stream map of the dialysis process. This value stream will allow them to see the time it takes for each step of the process and look for target areas to improve upon.

We then presented our recommendation with a Pugh matrix, which clarifies how we weigh each factor in our decisions and what our overall best choice for them would be. These design recommendations outline our vision on how to improve the efficiency of the peritoneal dialysis alert system, nurse schedules, and/or standard operating procedures (SOP) for relevant tasks and scenarios.

Design CriteriaThe alternative designs that our team devised were evaluated and ranked on specific criteria to see ultimately which design is the best. This criteria includes reduced process time, implementation time, increased quality of care, and nursing staff acceptance. The Pugh chart in Appendix 2 takes into account all of these criterias and allows us to see in theory which alternative design is the best. The three preliminary alternative designs are having a dedicated off-site PD nurse, having a designated substitute charge nurse to take the place of the charge

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nurse when they leave for peritoneal dialysis, and or training other off-unit nurses in peritoneal dialysis so that the charge nurse of the 6B unit does not have to leave the unit as frequently. The Pugh chart shows that having a substitute charge nurse would be the best option out of those three.

Our data collection methods have the same structure, but will focus entirely on historical data and current nurse self-collected data. We have detailed notes of our previous preliminary observations and interviews, which were useful when contextualizing possible inefficiencies and suggestions that come from the data. Due to COVID-19 guidelines put out by the CDC and UMHS, we were forced to stop our in-person observations and time-studies.

As a result of the new project guidelines, we did not present the clients with a simulation. Time studies and further on-site observations were necessary to make a thorough and justified simulation of the charge nurse procedures and schedules; hence, a simulation is no longer relevant to the project.

Data Collection and Analysis MethodsThe two main sets of data that were gathered were self-collection data from the charge nurses and in-person observations that the team have completed.

Charge Nurse Self-Collection Nurses were previously asked to record how long they spend performing peritoneal dialysis duties, but that data has yet to be verified by an independent source. Self-collection can be subject to personal bias, while time study data that is collected by the team can be influenced by the team’s presence in the nurses’ working environment. Through previous observations and interviews, it is clear that the charge nurse’s resources are spread quite thin, tackling a plethora of other tasks that do not always involve peritoneal dialysis. This reality implies that self-collecting specific data after setting up peritoneal dialysis for patients can be inconvenient, and costly toward completing other priority tasks. Additionally, COVID-19 has added an exorbitant amount of stress on the Unit and the entirety of UMHS. In response to these circumstances, it is our hope that additional data will continue to be recorded by the charge nurses completing the tasks whenever possible, but not at the expense of other priority tasks. As a result, even with some nurse self-collected data, Unit 6B can begin to thoroughly track its performance over time and establish a clear precedent for what additional resources and process improvements are needed.

The results of this historical data can be seen below in Table 1 with a sample size of 120 data points and in units of minutes. The “low” and “high” represent the minimum and maximum values across the samples in each category. The tasks in bold are the five tasks with which the team can start to make assumptions on, as those five tasks have been self-collected at least seven

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times, which was selected by the team as a viable data set given the small sample size. Within these five tasks are the two tasks which have the largest means and standard deviations, also bolded in the table. These tasks appear to be more significant than the other tasks.

Table 1: Summary of Historical Data of Self-Collection Performed by Charge NursesTask

ID TaskNumber of samples

Mean (min)

SD (min) Low (min)

High (min)

A Travel Time 43 3.42 2.17 1 10

B

Time Off Unit with Patient (CVC, ICU, ED, Women's)

41 8.66 7.12 1 27

C Review Orders 12 2 0 2 2

DGathering supplies and prep 8 2.25 1.16 1 5

ECommunication with Nephrology 7 14.29 21.5 3 62

F Communicate with RN 2 2 0 2 2G Delivered Supplies 2 6.5 2.12 5 8H Troubleshooting Cyclers 2 2.5 0.71 2 3I Mid day Exchange 1 5 0 5 5J Post Drain 1 5 0 5 5K Research 1 15 0 15 15

Figure 1 below helps illustrate mean and standard deviation for the five tasks with sufficient data.

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Figure 1: Task B (Time Off-Unit) and Task E (Communication with Nephrology) are significant

The historical data shown in Table 1 reveals that there are only five tasks with sufficient data. Those five tasks were travel time, time off unit with patient, review orders, gathering supplies and prep, and communication with Nephrology. Of these five tasks, the team found two tasks, time off unit with patient and communication with Nephrology to be significant. The team took into consideration the amount of time the task took as well as the standard deviations with respect to the means of each category when considering what made these two tasks significant. Both of these tasks on average took the most amount of time to complete (time off unit with patient: 8.66 minutes, communication with Nephrology: 14.29 minutes), along with having the highest standard deviations (time off unit with patient: 7.12, communication with Nephrology: 21.5) which intrigued our team. In an ideal situation, the team would want our data to be as minimally varied as possible. The best way to do that is to try and standardize these operations to make sure the process is performed closest to that standard every time.

Changing the format of the self-collection data sheet has been discussed with our team. As of now, the charge nurse has to write down each task along with the allotted start and finish times. One idea is to change this format to make the process much quicker. Instead of having to write down each task and the time, it would be more beneficial if the process was standardized into a set of tasks each setup. Thus, the team could create a form that has all of these tasks, and give options of how much time it took the charge nurse to complete action, so that they can just check

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the time off, making the process much quicker. Another idea is to do frequency tests instead of timing each task.

In-person Team ObservationsDirect observation is the most detailed method for the team to understand the full process of peritoneal dialysis. The team wanted to observe as many responses as it takes until strong and minimally variable data was attained. As of now the team has performed enough observations in order to create a standardized process of collecting data for what the team wanted to collect while observing. In accordance with COVID-19 guidelines, we could not continue to collect data in-person in any fashion. This would mean that in the future, or for follow-on student groups, we recommend to collect time data that include the following: the length it takes to gather supplies, the length it takes to connect all the bags to the cycler unit, the length it takes to prime the cycler, the length it takes to connect the bags to the patient, and the length it takes to respond to an alert. Other time studies that are crucial, yet outside the formal process of off-unit PD exchange, include: the length it takes to find a substitute charge nurse and the length the charge nurse spends per shift taking inventory of the stockroom [and all recording and ordering associated with this task].

Data AnalysisTravel time, time off unit with patient, review orders, gathering supplies and prep, and communication with Nephrology are the five tasks in which the team can use to analyze some of the data since there are at least seven data points for each of the tasks. Table 2 shows the different confidence intervals for each of the tasks below.

Table 2: 95% and 99% Confidence Intervals for Feasible Tasks in Minutes

Task ID Task LowHigh

Lower CI 5%

Upper CI 95%

Lower CI 1% Upper CI 99%

A Travel Time 1 10 2.77 4.07 2.56 4.27

B

Time Off Unit with Patient (CVC, ICU, ED, Women's)

1 27 6.48 10.84 5.80 11.52

C Review Orders 2 2 2 2 2 2

DGathering supplies and prep 1 5 1.44 3.06 1.19 3.31

ECommunication with Nephrology 3 62 0 30.21 0 35.22

Confidence intervals are important to give us an estimate of range in which the real data point lies. They help find outliers in data in order to help alleviate any worries of data being too high

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or low. In this case, as you can see, the highest data points for our two significant tasks (time off unit with patient and communication with Nephrology) are much higher than the upper 99% confidence interval. In this case, these data points are outliers, and hold lower importance in the data set. For communication with Nephrology, the outlier in the data was the data point of 62. All other data points were at the least two and at the most fifteen. Without this data point, the confidence interval would be much smaller and less variable. The ideal confidence intervals are the smallest ones. This translates to the data set being as least variable as possible, which should always be the goal when collecting data.

In addition to developing confidence intervals, we also developed a current state map to determine what elements of the peritoneal dialysis setup are non-value added, and taking the most time. Figure 2 below shows the current state.

Figure 2: Finding a replacement nurse significantly impacts the NVA percentage

The major steps in the process are represented by the gray boxes, with the process beginning once the charge nurse reviews the order placed by the Nephrologist, and ending once the peritoneal dialysis cycler machine begins. Additional tasks such as finding a replacement nurse to lead the unit and traveling to the peritoneal dialysis patient are represented by arrows connecting the boxes. Finally, the average time required for each step is below each major process step and at the very bottom in a timeline, where the elevated portions represent Non-Value-Added (NVA) time, and the lowered portions represent value-added time. As one can see, the percentage of time that is non-value-added is at 30.5% right now. The largest contributor to

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that percentage is the 20 minutes used in finding a replacement nurse to lead the unit. It is evident that in order to reduce the percentage of time that is NVA, this problem will have to be addressed.

Literature Search It is likely that the higher number of patients to every one nurse will cause stress on the productivity of the charge nurses in study. “This study provides empirical evidence that RN staffing, as well as the processes of care provided by RNs, are essential to reducing the odds of adverse patient events in dialysis units.” [1]. This idea was found to be consistent with our numerous charge nurse interviews: when more patients come in, they have to triage every action that needs to be done, so every patient can begin their exchange. From our findings, reporting and all paperwork involved with tracking measures taken is the first thing to be skipped or delayed. The level of stress on the system produces an issue in the scope of continuous improvement; without honest and consistent data collection, 6B does not have evidence of a way to improve. From all accounts, UMHS Unit 6B prides itself on hiring skilled and bright individuals, but even with core competencies accounted for, problems in work design and workforce management endanger provision of care.

“Staffing is important because it has been identified as a structural measure of quality. With 326,671 (93.1%) of all dialysis patients receiving in-center treatments, this is a potentially critical issue” [2]. Our team has seen through staff interviews and on-site observations that the charge nurse responsibilities have a vastly larger scope than the team of RNs on staff. It is apparent in Unit 6B that some solution, whether it be process change, increased staffing, improved predictive scheduling, and or reassignment of roles and responsibilities, is necessary to break the trend of overwork being a detriment to the quality of care in-clinic.

The current body of work referenced in this paper is sufficient for guiding this project through to the formulation and deliverance of recommendations to the client. Additionally, by nature of these sources, a lot of the evidence presented is from larger collections of work which inherently provides a broad scope of research for the team to consult.

Alternative SolutionsThe team has come up with a few preliminary alternatives that could help resolve the problem of the absence of the charge nurse when they perform the process of off-site peritoneal dialysis.

The first alternative is to hire a designated off-unit peritoneal dialysis nurse. The on-site charge nurse would then be able to tend to tasks that deal solely with the 6B unit, and would be able to help the other nurses when needed.

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In the circumstance that hiring a designated off-unit nurse is not possible, our team suggests that all on-site substitute charge nurses will be scheduled at the beginning of the week when the schedule is published. The other nurses of the 6B unit would be able to look to the on-site substitute charge nurse for help as they would normally with the charge nurse if they were present. In addition, this solution saves time and clarifies responsibilities by designating this crucial on-site leadership role prior to the start of the shift.

The last alternative is to train nurses in other departments that have PD patients on how to set up and manage peritoneal dialysis exchanges, so that the charge nurse from the 6B nursing unit would not have to travel to off-site floors to set up the patients themselves. Making all of the nursing units self-sufficient in PD patient care would allow for the 6B charge nurse to spend more time leading the 6B nursing staff. The team has created a Pugh matrix located in Appendix 2 below that breaks down which alternative solution the team has deemed as the best option.

RecommendationsThe team has also identified a few possible process improvements that can increase the efficiency of the peritoneal dialysis process. One improvement involves standardizing the process in which the charge nurse locates and notifies the substitute charge nurse for that shift. This improvement ties in greatly with publishing a clear schedule for the charge nurse. A method to standardize this process would be to establish one device as the primary form of communication between the on-site substitute charge nurse and the off-site charge nurse.

Another improvement that would reduce over-processing and increase work efficiency for the charge nurse is to standardize the preparation of all inventory in the nephrologist’s orders. Often the charge nurse from the day shift preps the fluid bags for the charge nurse working the night shift to help speed up their work. However, the charge nurse for the night shift still has to verify all the prepared inventory to ensure compliance with the nephrologist’s orders. Limiting the over-processing of preparation will save time and free up the nurse during the day shift.

Currently, charge nurses are responsible for logging stockroom inventory, while clerks are responsible for ordering that logged inventory. This can be improved by designating the logging and ordering of inventory to clerks. This would involve extra training for the clerks to allow them more agency in managing the current inventory system. This is another opportunity to redefine responsibilities in 6B which would further alleviate the excessive workloads experienced by the charge nurses.

These recommendations are featured in Figure 3, as yellow Kaizen bursts. The red tornadoes represent the impacts these changes have on the process. As one can see, simply by standardizing the process of finding a replacement charge nurse, the estimated duration of this step is reduced

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from 20 down to 1 minute. This leads to an overall Non-Value Added percentage of only 7.67% (down from 30.5%) .

Figure 3: Standardizing the Process of Finding a Replacement Nurse reduces NVA by 22.83%

Expected ImpactThis report seeks to demonstrate how much time Unit 6B charge nurses are spending to complete tasks related to off-unit Peritoneal Dialysis set-up. The report also provides three solutions to issues that were identified during in-person observations. These recommendations focus on minimizing non-value-added time, reducing over-processing, simplifying communication, and overall improving the utilization of the charge nurses’ time.

Future IOE 481 Project Group PossibilitiesIn the circumstance that Michigan Medicine wants to have another student group work on the peritoneal dialysis process, the team has a few recommendations for how they could expand upon our work. We recommend completing as many direct observations as possible. Due to COVID-19, our team had to stop direct observations and rely on limited quantities of nurse self-collected data. While this data was helpful, we found that direct observations were integral to our team’s comprehension of the project. When directly observing the process, it affords more opportunity to conduct time studies and contextualize any new data in a coherent and consistent manner. We also recommend to unit 6B that all opportunities to self-collect data should be taken to compile a large and reliable dataset for later in-depth analysis.

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We think future teams should use both the historical data as well as the aforementioned time study data collected by the team to expand on our current and future state value stream maps by conducting more observations. Creating these value stream maps to target inefficiencies and improve these areas will prove crucial when identifying new solutions.

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References

[1] Thomas-Hawkins, C., Flynn, L., & Clarke, S. P. Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units. Nephrology Nursing Journal, Mar. 2008. Accessed on: Jan. 20, 2020. [Online].Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845981/

[2] W. A. Wolfe, Adequacy of Dialysis Clinic Staffing and Quality of Care: A Review of Evidence and Areas of Needed Research, American Journal of Kidney Diseases, Aug. 2011. Accessed on: Jan. 20, 2020. [Online].Available: https://www.sciencedirect.com/science/article/abs/pii/S0272638611008122

Annotated Bibliography

Thomas-Hawkins, C., Flynn, L., & Clarke, S. P. (2008). “Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units.” Nephrology Nursing Journal : Journal of the American Nephrology Nurses' Association, 35(2), 123–131.

The journal paper considers the relationship between hemodialysis nurse staffing and patient outcomes and task completion. It asserts that high patient-to-nurse ratios cause adverse patient incidents as well as higher quantities of incomplete tasks. This source is useful for our project because it demonstrates that stressing dialysis nursing resources encourages defects in the process of caring for patients, warranting creative solutions to prevent overworked nurses. In our project specifically, it is apparent that the 6B peritoneal dialysis unit has room for improvement with respect to scheduling, staffing, and resource allocation.

W. A. Wolfe, “Adequacy of Dialysis Clinic Staffing and Quality of Care: A Review of Evidence and Areas of Needed Research,” American Journal of Kidney Diseases, vol. 58, no. 2, pp. 166–176, 2011.

The quality of care is impacted by both the experience of the nurses and nurse scheduling of the unit. Focusing specifically on dialysis nursing, a robust collection of evidence was presented to assert that low nurse-to-patient ratios fueled high turnover rates due to occupational burnout; ultimately, making quality of care lower because of the scarcity of very experienced dialysis nurses. This is important because the central focus of our project is the charge nurse position, likely the most seasoned nurse on shift who can assist all other nurses and manage all off-unit exchanges. Gathered from client discussions, it is evident that unit 6B has the same issue of retaining a large number of seasoned charge nurses which may be due to scheduling issues and the inherent challenges inflicted by the variability of patients incoming needing peritoneal dialysis around the hospital.

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Appendix 1: Constraints and Standards Matrix for 6B Charge Nurse Off-Unit Peritoneal Dialysis Work-Load

Organizational Ethical Health & Safety

Constraints

Mode of Transportation in Hospital

Elevator Wait Times

Number of Charge Nurses caring for off-unit PD patients

Nurses who can set up off-unit PD patients

X

X

X

X

Standards

HIPAA

X X

COVID-19 X

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Appendix 2: Pugh Matrix for 6B Charge Nurse Off-Unit Peritoneal Dialysis Work-Load

Current State

Dedicated Off-Unit PD Nurse

Designated Sub-Charge

Nurse

Train Off-Unit Nurses in PD Setup

Criteria

Reduced process time 0 +1 +1 0

Implementation time 0 -1 +1 -1

Increased Quality of Care

0 +1 +1 +1

Nursing staff acceptance

0 +1 0 -1

Cost 0 -1 0 0

Totals 0 1 3 -1

Rank 2 1 3

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Appendix 3: Updated Gantt Chart

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