Sunday, October 19, 2008

SPIRITed Transport

It has been some time since I gave you an update on BIDMC SPIRIT, our employee-driven process improvement effort. In addition to a variety of small projects, we have focused on several large hospital-wide attempts to improve the work environment. One of them is the issue of transporting patients to testing. As I noted back in June,

There have been several SPIRIT call-outs by transporters and other staff related to miscommunication about the mode of patient transport. A request is made for one means of transport (for example, wheelchair), yet another means of transport is what is brought (for example, a stretcher).

At the time, we found the following underlying symptoms:

There is a communication disconnect between Service Response, the testing location, and the unit to which the patient is assigned.
There are no clear cut guidelines as to who decides the mode of patient transport, or when, or how.
Nursing’s way of determining how to send a patient differs from how the testing location might want to receive the patient. Each use different criteria. An unfortunate side-effect is that the transporters are caught in the middle of communications between senders and receivers.
When Service Response gets a call for a patient transport request, the level of detail varies depending on who took the call.
(Interestingly, Radiology has its own system, in which they call the unit to confirm “we’re coming to pick up Patient X in a wheelchair,” but still they end up with the same problem. When they arrive, it turns out that the nurse requested a different mode of transport.)

And here's what we said we'd do:

We are in the midst of collecting a baseline for Radiology and Central Transport on the West Campus. This includes the number of transports per day, and the number of “wrong” modes for each day. This also includes overall transport time. The anticipated time to implementation of a solution is about 4 weeks.

Well, it turns out that this took a lot longer than 4 weeks, but it is because we expanded the scope of the project so it became a design from scratch of the process used by all parties involved in transporting a patient between an inpatient unit and a testing area (e.g., radiology). Go-live for the new approach is this Tuesday. What follows is an outlined summary sent to me by one of our Senior Vice Presidents. She was keen to note that the effort involved participation, suggestions, and energy from people at all stages of this process, exemplifying the whole idea of BIDMC SPIRIT, lots of well intentioned people working together for the good of patients and each other.

We'll see how it goes on Tuesday! As the summary below anticipates, no doubt there will be some glitches, for -- as anyone in any hospital can tell you -- this is a complicated environment. But I hope that you get the point that even solving the glitches together is part of the idea.

Where did we start?

Multiple SPIRIT callouts re: mode of patient transport (e..g., transporter arrived on unit with stretcher, nurse thought patient should go in wheelchair.)
Resulted in:
Transporter hunting and fetching;
Delays (impacts our patients, our nursing unit staff, our testing areas, our transporters and transport times, etc);
Sometimes patient went to testing unit on mode that couldn’t be used in that test; test had to be rescheduled;
Confusion among transporter, nursing unit, SRC and testing area staff.

After discussion among representatives of all staff involved, the group determined that entire process of transport (not just choice of mode of transport) from inpatient unit to testing area was:
Not defined/standardized;
Created re-work and delays;
Included less than optimally safe practices;
Created frustration/tension among departments (RNs, UCOs, SRC, transport, testing areas);
Would provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

Decision to broaden scope of project to entire process: Starting with request for transport and ending with patient return to unit following test.

What process did we use to design new process?
Front line staff from each area described to each other current practice and problems and found that:
Process differed by unit and testing area;
Some groups are doing extra work that they thought helped other group, but didn’t;
Identified lots of rework and potential for confusion;
Terminology is not defined consistently, leading to confusion;
It was very valuable to learn how all parts fit (or don’t fit) together.

We drew process flow for entire current process, listing all problems/potential for errors, then described “ideal” state and draw a new process flow (making sure we used “Lean” principles” described below) to reach that.

3. Entire group developed specific steps for each activity in pathway, understanding each others’ roles.
Tweaked process flow as specifics required.
Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

4. Developed approach and materials for staff education, roll out and continued improvement of new process.

“Lean” principles used to shape “Ideal” new process
“Activity” Principle: Specify all steps in process.

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately.

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow.

“Improvement” Principle: Use scientific method (data driven, evidence based), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New Transport Process
Testing area determines mode of transport (exceptions only permitted based on patient clinical condition and only after resource nurse discussed with testing unit to ensure that test could still be carried out).
Only one call made to Unit to schedule patient test, with standard set of info using standard nomenclature. (Currently, many testing areas call several times to give “heads up” of when test probably will be. Nursing staff noted this does not help them.)
Time communicated is the scheduled pick-up time (not test time). That’s what matters to the nursing unit and transporter.
All testing locations to schedule tests/transport via phone (some were using fax, causing staff to look for info in different places)

Patient Preparation:
Clear assignment to and definition of role of UCO in chart preparation and notification of RN re: transport.
Increased communication and established time frame (5 minutes) for nursing assistance with patient departure or arrival.
Involvement of the Resource RN to assist transporter if delay of 10 min. occurs
15 minute maximum time for transporter to wait before going to next job.

Face-to-face handoff must ALWAYS occur between patient’s nurse/designee and transporter upon patient’s departure AND return to unit. (Important safety improvement and will ensure that patients are receiving appropriate information).
Nursing unit staff ALWAYS to assist transporter in transferring patient to/from stretcher or wheelchair (important safety issue).

Continuous improvement:
Members of design group shadowing transporters first 2 weeks;
Managers assigned to serve as extra “help chain” for first 2 weeks so as much “real time” review of calls outs can be done;
Encouraging call outs for whenever process doesn’t work as designed (and underscoring it’s nobody’s fault);
Meeting 2 weeks post go-live to review all call outs and tweak process (and/or education) as needed.

Bottom Line
Reduction in time-wasted hunting & fetching
Alleviation of frustration and confusion (for both staff and patients)
Clarity in role responsibilities re: transport
Consistent and standard communication throughout patient transport process

= Improved Patient Care + Improved Employee Satisfaction and Collaboration + Better Use of Resources (through minimizing delays)


Anonymous said...

This is an impressive process and show admirable attention to the details that can make or break success. Thanks for spelling it out so clearly.

Anonymous said...

The SPIRIT entries are among my favorite on your blog. They're very interesting and I learn something from them that I can apply elsewhere, including in family life!

Anonymous said...

How about founding a clearinghouse (group on Facebook as a start?) where other hospitals can come to view solutions like this and emulate them, or tweak them for their own use? It'd have to be a forum with wide readership (not that your blog isn't, I hasten to say!)
As I've said before, it's a shame and expensive for every hospital to have to reinvent the wheel. As those of us who have worked in hospitals know, this is a ridiculously common problem.
Good work!


Anonymous said...

nice one...

Anonymous said...

"Spirited Transport".. nice title. :)

fibrowitch said...

You know I will be putting this process to the test shortly.

I like reading about your attempts to create a best practices for your hospital. The best CEO's are the ones who make sure all the different groups work together.

Karen Dayle said...

First time to visit here i just want to say your blog is so cool! :) Great Job

Kristina said...

Interesting discussion. Thanks for sharing this. Your contribution is really(and creativity) appreciated. :)