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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