Sustainment of Standardized Cardiac OR to Intensive Care Unit Transfer of Care. Tracie Northway, RN, MSN, CNCCP(C) & Lisa Yarske, RN, BSN, CNCCP(C)

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1 Sustainment of Standardized Cardiac OR to Intensive Care Unit Transfer of Care Tracie Northway, RN, MSN, CNCCP(C) & Lisa Yarske, RN, BSN, CNCCP(C)

2 # of Patients Identification of a problem Condition of cardiac patients upon receipt was historically unstable BCCH PICU Surgical Admission Breakdowns (2008) Cluster/flock care Chaos Delays in care No clear communication Missed critical information Surgical Service

3 Creating change: Take 1 New additions to CVS team Questioning of current practice at BCCH Review of cardiac program Team reps to Philadelphia for review of practices Team agreed on new approach for admissions Ideas implemented

4 Results of Take 1

5 Take 2: improve with Lean Capitalized on region wide Lean improvement process Appeal of better understanding with prep 1 week of dedicated collaborative improvement time Stakeholders wanted change

6 # of Defects What were we trying to improve? Decrease barriers (defects in Lean language) to increase clarity within roles for a safe handover between OR & PICU Teams Prior to improvement week the following defects were observed in cardiac OR to PICU handover Role crossover Tangled equipment/lines 3 3 Defects in Cardiac OR to ICU Transfer of care Supplies not where needed Increased unexplained staff Defect Category Waiting for people Deviations from "norm" "Presence" at handover OR Admit #6 OR Admit #5 OR Admit #4 OR Admit #3 OR Admit #2 OR Admit #1

7 RPIW #4 Team & Plan Team Sponsor Lynn Coolen Program Manager, PICU PICU Reps Andrea Yuel (RN) Lisa Yarske (CNL) Tracie Northway (Q&SL) OR #4 Reps Bill Cooper (Anaesth Assist) Clayton Reichert (Anaesthetist) Melanie Ganshorn (CRN) Neil Casey (Perfusionist) External Reps Alecia Robin (improve) Barb Fitzsimmons (VP BCCH) Erin Miller (Executive Assistant Corporate) Plan for the RPIW #4 week (March 23 rd -27 th, 2009) 1. Determine characteristics of a safe patient handover from OR 4 to PICU 2. Define process, roles & responsibilities ( standard work in Lean language) for a safe patient handover 3. Create tools to guide & support standard work 4. Test standard work tools

8 Standard work Used past cardiac OR project work, Great Ormond s Street handover protocol & participants ongoing input to define: Pre-transfer standard work: PICU bed preparation PICU bedspot set-up Perfusionist s report & confirmation of PICU admitting team Transfer standard work: Transfer process Technology transfer process Handover process

9 Support tools

10 Support tools

11 Support tools (cont d)

12 # of Defects Measured Outcomes BCCH PICU & Cardiac OR Pre & Post RPIW Defects per Handover Pre RPIW Average/Handover Post-Kaizen Average/Handover Role crossover Tangled equipment/lines Supplies not where needed Increased unexplained staff Waiting for people Deviations from "norm" "Presence" at handover Type of Defect

13 Measured Outcomes

14 Workshop Summary Broke down barriers & sacred cows between OR & PICU teams Developed a better understanding & appreciation for our teams and the work they do Determined characteristics of a safe patient handover Defined standard work for a safe patient handover Created & tested tools for standard work (Bedside Set-up Visual, Handover Checklist & Interprofessional Handover Protocol) You actually know what s going on [with your patient]! Quote from PICU CRN after participating in standard work of safe patient handover.

15 Follow On Responsive adjustment of Handover Protocol based on practice changes Anecdotal comments support change PICU staff have requested change in process for handover with other surgical services teams

16 Follow On Results: Two Years Post Change BCCH Cardiac OR to PICU Handover of Care Audits 100% 90% 80% 70% 60% 50% 40% 30% Pre Kaizen % of defects (defect/n of 6) Kaizen Wk % of defects (defect/n of 3) Post kaizen 2 yr Audits % of defects (defect/n of 19) 20% 10% 0%

17 References Black, J. & Miller, D. (2008). The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean. Health Administration Press, Chicago Catchpole, K., Leval, M., McEwan, A., Pigott, N., Elliott, M., McQuillan, A., MacDonald, C., & Goldman, A. (2007). Patient handover from surgery to intensive care: Using Formula 1 pitstop and aviation models to improve safety and quality. Pediatric Anaesthesia, 17: pp Ohno, Taiichi. (1988). The Toyota Production System: Beyond Large-Scale Production. Portland, Oregon: Productivity Press

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