As the health care. Earning Your Gait Belt in Lean: Stopping the Line Through a Staffing Response Team. Denise D. Fall, DNP(c), RN, CENP

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1 Earning Your Gait Belt in Lean: Stopping the Line Through a Staffing Response Team Denise D. Fall, DNP(c), RN, CENP As the health care industry struggles to adopt Lean practices from our colleagues in manufacturing, translating those concepts to the frontline staff and leaders can be challenging. In an effort to increase value to our patients by eliminating waste, increasing standardization, and engaging the expert frontline staff in problem solving, many of us struggle with translating the core concepts of Lean, let alone earning a coveted green or black belt. Health care systems such as Virginia Mason, Theta Care, and Stanford may have successfully implemented many of the practices that will earn a green or black belt of distinction, but for many of us, just like a gait belt, we are looking for something to provide security and support to stabilize our efforts. We continue to require reinforcement that we are following the core principles of Lean and are heading in the right direction. FROM PRODUCTION TO PATIENT CARE Although the foundation of Lean is more commonly found in the manufacturing industry, over the past 10 years, we have seen an increase in the number of health care organizations choosing to utilize and adopt the core principles of Lean to achieve high quality care. 1 The fundamental principle in Lean is to engage and empower the frontline staff. It is the staff s role to perform problem solving, not the leader. 2 In Lean process improvement, the role of the leader is to support the frontline staff to ensure patient care needs can be met as efficiently and as effectively as possible. 3 Many of the tools utilized in Lean and Six Sigma have crossed over nicely to the health care environment: value stream mapping, Kaizen events, fishbone diagrams, and A- 3s, 1(p.164) yet the core concepts can be harder to translate or actualize. One core concept that proves to be more challenging to translate in the health care environment is that of stopping the line. Liker states, jidoka, which is referred to in Japanese as equipment which is endowed with human intelligence to stop itself when it has recognized a problem, 4(p.129) defines the concept of stopping the line as preventing a problem from continuing to be replicated. Even as American Nurse Leader 343

2 Figure 1. Helping Hands Task List Figure 2. Staffing Response Team Algorithm IV, intravenous; IVF, intravenous fluids; HOB, head of bed; LDA, line, drain, and airway; QC, quality control. manufacturing companies began to adopt Lean, the concept of stopping the line proved to be challenging. The underlying goal is to ensure that problems, once recognized, are not passed on, building quality improvement into day-to-day operations. 4 If stopping the line in manufacturing, which is dealing with inanimate objects, creates angst, consider the complexities in attempting to create that culture in the health care environment where human beings are involved. Challenging as it may seem, the value in creating a culture where quality is actively being assessed and improved upon may have a profound impact on the delivery of health care in America. As health care moves from a volume-based industry, where revenue is solely generated on the numbers of patients/procedures, to one of value and limited exposure to risk/harm for the patient, our ability to improve and address staffing needs must follow suit. In 2001, the committee on Quality of Health Care in America 5 outlined 6 aims to improve the delivery of health care in America. The 6 aims safe, effective, patient-centered, timely, efficient, and equitable are all influenced by those delivering care. 6 Improving the processes and determinants around nurse staffing (those providing the care) supports the foundational goals related to improving the delivery of care in America. As the single largest labor cost in the acute care arena and one of the largest drivers in clinical outcomes, nursing is poised to be the focus of a value-based delivery system. 7 PSA, patient safety alert. Staffing models that ensure organizational resources and nursing competencies are aligned with a patient s unique needs will become central to the conversation. 8 The ability to respond to the volatile nature of staffing in any given unit, on any given day, may improve quality and staff satisfaction. Current research on missed nursing care has linked inadequate staffing as a determinant in care environments. Increases in missed care are tied to decreases in quality of care, as well as decreased engagement and satisfaction of the nursing staff. 9 In evaluating missed nursing care, a correlation between skill mix and staffing determinants is noted. 10 A sense of frustration and despair is noted from nurses who report an inability to meet to the needs of their patients. Unfinished or missed care is tied to negative outcomes for patients, the nurses caring for them, and the organizations they are working in. 11 Adaptive responses in teams demonstrated lower levels of missed care and a decrease in feelings of moral distress and dissatisfaction from the nursing staff. 11(p.1133) STOPPING THE LINE TO ENSURE QUALITY AND ADDRESS STAFFING NEEDS In late 2013, Legacy Salmon Creek Medical Center, a 220- bed community hospital in Vancouver, Washington, was responding to a 35% increase in volume related to contractual agreements and the Affordable Care Act. Although traditional 344 Nurse Leader October 2016

3 methods (increased hiring, overtime shift incentives, utilization of a system-wide resource pool, and the use of agency staff and travelers) were in place to address the increase in volume and ensure staff had the needed resources to provide high quality care, it was clear that these methods alone may not be enough. Staff satisfaction surveys and discussions with staff during rounds indicated that at times, the staff still felt pressure from the increased volume. Many felt they were working in chaos and did not have the support needed in the moment. Utilizing the site-based, state-mandated staffing committee, which has frontline representatives from each unit and limits leadership participation/representation to 50% of the total attendees, as a safe place for staff to share their concerns and stories, the team was challenged to think of creative solutions to solve the identified problems. Current initiatives to increase staffing were shared and discussed. Although the staff appreciated the work being done, what they recognized is that even when volumes are not high, there are times that they need to stop the process to determine how best to proceed to ensure the quality of care does not suffer. In continued dialogue, the team mentioned having the ability to access clinicians and support staff at a moment s notice would be the most helpful. In listening to their discussion, the leaders questioned whether they were talking about something similar to the system s rapid response team (RRT). The RRT was developed in 2005 to bring clinical expertise to the bedside if staff noted a change in patient condition warranting additional assessment or support. Highly valued, the RRT model resonated with the Salmon Creek staffing committee, and they began to outline a proposal for a staffing response team (SRT). A STAFFING RESPONSE TEAM The team began outlining/implementing the process using plan, do, check, adjust (PDCA). 3 Plan Who would respond? Responders would include the nursing supervisor, housekeeping supervisor, and available leadership, but more importantly, the charge nurses on every unit would identify and send available staff to the unit requesting assistance, ensuring patient care was not compromised on additional units. What would those responding be called upon to do? The team outlined tasks that any staff member could perform, and that would allow staff to safely provide clinical support based on licensing and competency levels (Figure 1). Where would the team respond? The team responds to any unit or department where patient care is being delivered and an urgent staffing need has been identified. When would a unit or staff member call? Staff are encouraged to request the SRT anytime they identify there is an urgent staffing issue and help is needed immediately, when there is a staffing issue or flow issue that cannot be resolved with the available resources on that unit, or when the unit s Figure 3. Staffing Response Team FAQ FAQ, frequently asked questions; i-care, organization term for patient safety alert. charge nurse/assistant nurse manager/manager needs additional help to resolve a staffing or flow issue. How would the call be made? Calls are made utilizing the same standard process for other emergency requests (RRT, code blue, etc.). Utilizing a standard process ensures consistency and eliminates confusion for the house operators, staff, and leadership. Why create a staffing response team? The staffing committee wanted to utilize the expertise and resources on site to solve an immediate problem or issue. The committee saw this as something they could own and address to provide value to their colleagues and patients. The team wanted to ensure staffing needs did not compromise or impact the quality of care being delivered. Do The committee worked collaboratively with senior leadership, and support services to ensure there was support and understanding of the process throughout the hospital. The team developed education for the entire staff, they developed an algorithm (Figure 2) to help staff visualize the process and an FAQ sheet (Figure 3) for staff and leadership. The team utilized an education software system to assign education to all staff. Members of the staffing committee attended staff meetings and provided poster board presentations that were used during site-based skills days and during individual unit learning sessions. Nurse Leader 345

4 Figure 4. Staffing Response Team Debrief Form Check The team wanted to ensure the SRT was meeting the needs of frontline clinicians, so they developed 2 mechanisms that allow for follow-up, review, and further issue identification. A debrief form (Figure 4) was developed to capture in the moment information that the committee would be able to review monthly. The team engaged the internal process of reporting concerns or issues through patient safety alerts. Utilizing a standard mechanism ensured transparency and accountability of senior leadership at the site level. Adjust Just like in manufacturing, there is a hesitancy to stop the line. In order to instill confidence and destigmatize the process, the staffing committee now schedules monthly mock SRTs, which have helped staff to be more inclined to initiate a call when they recognize the need. During the monthly review of the SRTs, the team looks for trends and questions whether a process change needs to happen. During monthly reviews, the committee noted that the responders shared that some units wrote Post-it notes with assigned tasks, and they commented on how helpful it was to the SRT responders. The staffing committee has used this information to adjust the process and educate all charge nurses on the process of using Post-it notes. After a recent SRT to the neonatal intensive care unit (NICU), the team decided to trial stick-on name badges noting specialty area and role (e.g., NICU RN, emergency department [ED] tech, volunteer), allowing the charge nurses to easily hand out assignments and help staff quickly identify responders potential skill sets. Staff have come to recognize the value of the SRT and stopping the line. The in the moment support and collective problem solving ensures that problems or issues do not continue, and quality care can be achieved. PROGRAM EVALUATION The SRT was implemented in April of Initial concerns by the staffing committee and leadership that the team would be burdened with inappropriate calls has been alleviated. Since implementation, the team has responded to 15 SRTs (Table 1). All SRTs have been reviewed and confirmed as appropriate. The team has responded to the ED, PACU, and every in-patient unit, including our NICU. The average number of responders is 12. The average length of the SRT is about 27 minutes. The general tasks performed include: medication administration, toileting patients, answering phones and call lights, performing admission and discharge duties, and assisting staff with breaks and lunches. The overall response has been very positive. Each SRT is evaluated at the monthly staffing committee meeting. The comments from staff on the debrief forms are positive: I was able to chart on 2 patients while my call lights were answered ; This is my first day working here and this is the best thing ever, I am so impressed"; I am definitely going to use the SRT again. In rounding with staff and through comments received in the annual staff engagement survey, staff comment on feeling supported and are encouraged by the number of responders. An unexpected outcome has been the support of our physicians and chief administrative officer who have made it a habit to respond, although not required to or always accounted for in the debrief form. As patterns emerge by unit or time of day, information may be used to influence more permanent staffing adjustments. IMPLICATIONS FOR NURSING With 14 states addressing nurse staffing in hospitals through laws or regulatory requirements, 12 it is imperative that the nursing community continues to actively engage in the topic of nurse staffing. Seven states have mandates related to staffing committees, which include Oregon and Washington. The underlying goal of the state-legislated staffing committees is to actively engage frontline nursing in discussions around appropriate staffing and problem solving. Leveraging the expertise of those doing the work will liberate innovative and creative ways to address work flow problems or concerns. Engaging the frontline staff to take ownership of their nursing practice decreases the need for lobbyists and legislators to dictate how we deliver care. Although the Salmon Creek team has not aspired to obtain a coveted green belt or a black belt in Lean, they certainly have successfully translated a manufacturing concept to the health care setting to improve quality of care. Like a gait belt, they have developed a mechanism to provide support to their colleagues to ensure that quality and safety do not become unbalanced. As health care continues to reform, and current models are challenged, 346 Nurse Leader October 2016

5 Table 1. Staffing Response Team Data Unit # of Calls Average Time Call Lasted (Minutes) Events Leading up to the SRTs Medical/Surgical 5 17 Late sick call not communicated; unit short staffed. RN with PACU & cath lab backto-back admissions. RN felt overwhelmed, staff had been sent home Short Stay/PACU 2 42 Six admits (2 urgent, 3 post-ops, one patient from cath lab); needing RNs to start IVs and admit patients, needing staff to perform EKG ED 1 16 ED received 3 code 3 ambulances and was holding an intubated ICU patient. Was the Unit Charge Nurse Was the Manager Average Number of Respondents Tasks Completed No Yes Yes 12 Med administration, pt. ambulation, call lights answered, emotional support provided to family, discharge completed, meal trays picked up and documented. Wound care, phones answered. Yes No 10 EKG, IVs started, admission documentation completed, rooms cleaned. Patients transferred to in-patient rooms. Yes Yes 10 Patients transferred Comments/ Suggestions Excellent response. Sticky notes were used. sstaff RNs actually created their own stickies, which helped CRN. Nice to have our physicians respond! Resolution within 15 min. Very supportive. Helpful to have charge RN assign tasks on post it notes. Great response. Felt supported. Awesome turnout. Great response, great job! Nurse Leader 347

6 Table 1. Staffing Response Team Data (cont.) Unit # of Calls Average Time Call Lasted (Minutes) Events Leading up to the SRTs Was the Unit Charge Nurse Was the Manager Average Number of Respondents Tasks Completed Comments/ Suggestions Progressive Care 4 22 Unexpected procedure, needing to be done urgently requiring 3 RNs. Multiple discharges and admissions taking place at once. High calllight volume, staff unable to keep up with patient needs. Yes Yes 11 Patients safely ambulated to bathroom, break relief, vital signs, and documentation. Lunch relief provided, patients admitted, call lights answered, phones answered. Have a list ready for those who come in response. The unit calmed in 30 min. Very positive. All responding staff were very helpful. Very helpful. This was a very well executed SRT. It was great to have prompt help. NICU 1 Not captured Not captured Yes Yes 14 Not captured Nurses were impressed with how many people showed up. Physician responded. IMCU/ICU 2 42 Four admits at change of shift, high acuity patients, multiple total cares, high call volume, high fall risk patients Yes Yes Not captured Med administration, bed baths, linen changes, call lights answered Better prepared when other departments arrive. Know what each department is able to perform within the scope of practice. Need a CNA on nights. Great turnout. Very helpful. CNA, certified nursing assistant; CRN, charge nurse; ED, emergency department; EKG, electrocardiogram; ICU, intensive care unit; IMCU, intermediate care unit; IV, intravenous; NICU, neonatal intensive care unit; PACU, post-anesthesia care unit; pt., patient 348 Nurse Leader October 2016

7 nursing needs to leverage its intrinsic expertise to redefine those models. Translating Lean concepts is one way to truly engage the frontline staff and empower them to impact the manner and environment in which they carry out their most basic mission. NL References 1. Shirazi SA, Pintelon L. Lean thinking and six sigma: proven techniques in industry. Can they help health care? Int J Care Pathw. 2012;6: Rinehart B. Applying lean principles in healthcare. Radiol Manage. 2013; (suppl): Albanese CT, Aaby DR, Platchek TS. Advanced Lean in Healthcare. North Charleston, SC: Create Space Independent Publishing Platform; Liker JK. Principle 5: build a culture of stopping to fix problems, to get quality right the first time. In: The Toyota Way: 14 Management Principles From the World s Greatest Manufacturer. New York, NY: McGraw-Hill; 2004: Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; Block DJ. Healthcare Outcome Management: Strategies for Planning and Evaluation. Sudbury, MA: Jones and Bartlett; Harper EM. Staffing based on evidence: can health information technology make it possible? Nurs Econ. 2012;30: Malloch K. Measurement of nursing s complex health care work: evolution of the science for determining the required staffing for safe and effective patient care. Nurs Econ. 2015;33: Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38: Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65: Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. Int J Nurs Stud. 2015;52: American Nurses Association website world.org. Accessed September 15, Note: The author would like to acknowledge the Legacy Salmon Creek Medical Center Staffing Committee for their desire to ensure a healthy and supportive work environment for their entire team and for their dedication to providing high quality care to the patients and families who seek their services. Special thanks to the staffing committee cochairs: Logan Kysar, BSN, RN, manager of the Legacy Salmon Creek cardiac catheterization lab, endoscopy unit, short stay unit, and post-anesthesia care unit, and Kim Mackinnon, RN, charge nurse for the Legacy Salmon Creek Women s Services, and to Bryan Payne, MBA, manager of Quality and Data Management (Legacy Health) for his artistic contributions and support. The author is proud to share that the SRT has been adopted at Legacy Good Samaritan with similar results. Denise D. Fall, DNP(c), RN, CENP, is the vice-president chief nursing officer for Legacy Good Samaritan Medical Center in Portland, Oregon. Denise can be reached at dfall@lhs.org /2015/ $ See front matter Copyright 2016 by Elsevier Inc. All rights reserved. Nurse Leader 349

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