Implementing learnings from conferences, literature key to improvement
The process of identifying innovative ways of improving the patient experience, then using lean methods to integrate those findings into our daily work is an important part of Virginia Mason’s vision of being a learning organization.
In health care, complacency too often stalls progress. Organizations focused within their own silos remain clueless about innovations elsewhere that could improve the quality and safety of care. Unfortunately, this sort of complacency is far from uncommon.
In contrast, providers that consider themselves learning organizations continuously search outside their own walls for ideas that can improve care for patients. In the complex, often turbulent world of health care, an insatiable sense of curiosity is no longer optional – it is essential.
This installment takes a closer look at Virginia Mason team members who have taken innovative approaches learned outside the organization and integrated those learnings as part of our efforts to improve the patient experience.
Barry Aaronson, MD
Barry Aaronson, MD, found gold in work being done by a team at Emory Healthcare in Atlanta on venous thromboembolisms (VTE), a dangerous condition where blood clots in the leg sometimes migrate to the patient’s lungs and become fatal. It is among the leading causes of death for hospital patients, taking tens of thousands of lives each year.
Dr. Aaronson, hospitalist and associate medical director, Clinical Informatics, was searching for a way to make sure clinicians and Virginia Mason were compliant with standard recommended practices for preventing the formation of these dangerous venous clots that could embolize to the lungs and cause grave damage.
This was an area where Virginia Mason was not performing to expectations. “We were getting it right 93 percent of the time,” says Dr. Aaronson, `”and that is not even in the top 10 percent of the country.
“It is a difficult issue because we are admitting the patient for a disease or condition, so prevention of an embolism is not what they are here for. Integrating work to prevent embolisms is difficult because clinicians are focused on dealing with the disease that caused the patient’s hospitalization.
“At a conference, Dr. Jason Stein from Emory talked about software he had developed to help identify defects in care process. It focuses on real-time feedback, telling clinicians in real time that you are not doing something you want to do. Without technology, defects have traditionally been identified retrospectively. But if we can get information to clinicians in real time we can head off serious problems.”
Dr. Aaronson and his team made the approach consistent with the Virginia Mason Production System by creating a clinical andon board − a signal updated in real time indicating when a patient was not getting needed therapy.
“It is basically a red light, a visual cue, that the patient is not getting the therapy they need,” he says. “We also placed a monitor on the wall of the Critical Care Unit (CCU) so everybody on the care team would be getting real-time feedback. It’s group situational awareness so that everyone on the unit can see that the patient is not getting what we as an organization decided to do.”
Dr. Aaronson believes humans can only improve care systems to a certain level and that “the only way to deliver mistake-proof care is with the help of machines.”
The clinical team studied the workflow to understand the current state and how best to integrate the new andon into the care process. The result was standard work where the charge nurse, a pharmacist and clinicians would monitor the board throughout the day.
And here is the great news: six months after this protocol was implemented in the CCU, there had been zero defects. “How does that translate into patient outcomes?” asks Dr. Aaronson. “We know patients would have died from VTE if we hadn’t done it.”
Once the VTE pilot is complete, the plan is to add other clinical quality measures to the andon board, and improved glycemic control is the next target. If the care team can be provided with real-time group situational awareness about patients who do not appear to be getting the care they need, the care delivery process can be mistake-proofed for those patients too. Ultimately, the hope is to monitor up to about 20 care processes with this technology, which should help Virginia Mason with its vision of becoming the Quality Leader.
Shirley Sherman, RN
“Ten years ago, I had the opportunity to participate in the Institute for Healthcare Improvement (IHI) Critical Care domain conference in Boston on improving critical care,” says Shirley Sherman, RN, nursing director, Critical Care. “I went with the CCU travel team, headed by (critical care medicine specialist) Mike Westley, MD. Attending the conference not only opened my eyes about the national improvement work and the networking prospects with colleagues around the country, but also the ability and value of getting on a plane and going out on a learning journey. It is quite amazing and extraordinary to network with my own organization’s peers in another state without getting paged, and the ability to compare and contrast what we are doing and benchmark with others.”
Sherman has been part of Virginia Mason teams that have implemented evidence-based bundles from IHI for ventilator-associated pneumonia prevention, glycemic control and central-line insertion, along with care improvement for delirium identification and early mobility for the critical care patient. She had read about the research and changing culture around early mobility at Intermountain-LDS Hospital and it sounded promising.
“To start mobilizing patients early in their stay in CCU can alleviate a host of complications, including delirium and weakness, prolonged time on the ventilator and extended stay in the critical care unit and the hospital,” says Sherman, who learned that Intermountain teams got their patients up and moving as soon as possible. When implemented at Virginia Mason, “critical care patients were walking the halls while still on the ventilator and even out to the roof garden and shower,” she adds.
While attending another IHI conference, a CCU team of nurses, respiratory therapists and physicians learned about work being done at Vanderbilt Medical Center in Nashville, Tenn. “We’ve taken this and other innovations to the local leadership level within Virginia Mason, and we look to make sure they are being done correctly. Are they understood by the staff? What are the barriers and how can we help solve those?”
Janine Wentworth, RN
Janine Wentworth, RN, administrative director, Hospital Patient Care Services, has been guided through the years by National Patient Safety Goals issued annually by The Joint Commission, as well as by goals from the Institute of Medicine (IOM), the Agency for Health Care Research and Quality (AHRQ), and from IHI.
Staying abreast of the latest ideas from these and other organizations is a direct benefit to patients, she says. “We have gotten ideas from all these organizations about improvements to our organization in a wide array of areas, including fall prevention, medication administration safety, and much more. And we always use lean principles to determine how best to make these innovations apply here.”
Information from the literature and conferences makes clear there is real danger when nurses are interrupted in the course of administering high-risk medications to patients.
“High-risk medication check is a nursing National Patient Safety Goal, and we used lean to come up with process for medication delivery,” says Wentworth. “We wanted to understand at what point in the medication delivery process nurses were most at risk of making errors.”
One thing Wentworth and her colleagues noticed was that pharmacists were delivering medications to the dispensing machine in the middle of times that were among the busiest for nurses dispensing medications. “It was built-in system disruption,” she says. “We talked with pharmacy to move their times of delivering medication, and it made a real difference. Ten years ago, it would have been very difficult for pharmacy to understand our need and for the nursing unit to understand pharmacy. But with our cultural transformation we were able to do it in a conversation.”
Standard work for high-risk medication distribution now requires Virginia Mason nurses to retrieve and dispense medication for one patient at a time, significantly decreasing the chances of a mix-up.
Wentworth and her colleagues have attended any number of conference sessions focused on preventing falls in the hospital. They have reviewed the latest literature and the bottom line is that while some organizations have made progress, no one has yet cracked the code.
“No one has been able to sustain improvement for very long, so we’ve had to figure it out on our own, and it is both extremely complex and nuanced,” Wentworth says. “Our goal is to get to zero injuries. We may still have patients fall with assistance and they aren’t injured. There is a balance here. It is very important to mobilize patients. If we protected them so there was no chance of falling, we would restrict beneficial mobilization.”
There remains much work to be done, but the encouraging news is that during the past four years, overall fall rates and falls with injury rates (per 1,000 patient days) have declined year over year.
What have you learned outside your organization that improved processes within your organization?