NSG451 in Healthcare Quality Improvement Paper

NSG451 in Healthcare Quality Improvement Paper

Innovation Series 2011 Hospital Inpatient Waste Identification Tool The Institute for Healthcare Improvement thanks the Health Foundation (Registered Charity Number: 286967) for its support in the development of this tool. 24 The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization that works with health care providers and leaders throughout the world to achieve safe and effective health care. IHI focuses on motivating and building the will for change, identifying and testing new models of care in partnership with both patients and health care professionals, and ensuring the broadest possible adoption of best practices and effective innovations. Based in Cambridge, Massachusetts, IHI mobilizes teams, organizations, and increasingly nations, through its staff of more than 100 people and partnerships with hundreds of faculty around the world. We have developed IHI’s Innovation Series white papers as one means for advancing our mission. The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and

ORDER A PLAGIARISM FREE PAPER NOW

early results where they exist. Copyright © 2011 Institute for Healthcare Improvement All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. How to cite this paper: Resar RK, Griffin FA, Kabcenell A, Bones C. Hospital Inpatient Waste Identification Tool. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org) Acknowledgements: IHI would like to thank the following individuals for their contribution to this work: Marian Bihrle Johnson, Research Associate, IHI; Elizabeth Bradbury, RN, Health Foundation/IHI Fellow, 2009-2010; and Gareth Parry, PhD, Research Scientist, IHI. The authors thank Don Goldmann, Jane Roessner, and Val Weber of IHI for their critical review of and editorial assistance with this paper. IHI is also thankful to the following hospitals that contributed to testing the Hospital Inpatient Waste Identification Tool: Great Ormond Street Hospital for Children, NHS Trust; Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust; Ninewells Hospital, NHS Tayside Board; Royal Bolton Hospital, NHS Foundation Trust; Royal Free Hospital, Hampstead NHS Trust; Salford Royal Hospital, NHS Foundation Trust; Blessing Hospital; and Memorial Hermann—Texas Medical Center. In particular, we thank Blessing Hospital, Memorial Hermann—Texas Medical Center, LifeBridge Health, and St. Anthony’s Home Care for contributing their stories and examples for this white paper. We would also like to acknowledge the following individuals who consulted with IHI in this work: Khalid Almoosa, MD, Medical Director, Transplant/Surgical ICU, University of Texas Health Science Center, Memorial Hermann—Texas Medical Center; Evan Benjamin, MD, Vice President, Healthcare Quality, Baystate Medical Center; Eric Dickson, MD, Senior Medical Director, University of Massachusetts Memorial Medical Group; Katharine Luther, RN, MPM, Director, Healthcare Improvement, Memorial Hermann—Texas Medical Center; Robert Merrick, MD, Medical Director of Quality Management, Blessing Hospital; Bela Patel, MD, Chief, Critical Care Medicine, University of Texas Health Science Center, Memorial Hermann—Texas Medical Center; Anna Roth, Chief Executive Officer, Contra Costa Regional Medical Center; and Sean Townsend, MD, Vice President of Quality and Safety, California Pacific Medical Center. Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 Telephone (617) 301-4800, or visit our website at www.IHI.org. Innovation Series 2011 Hospital Inpatient Waste Identification Tool Authors: Senior Fellow, IHI Frances A. Griffin, RRT, MPA: Director, IHI Andrea Kabcenell, RN, MPH: Vice President, IHI Catherine Bones, MSW: Project Director, IHI Roger K. Resar, MD: 1 Innovation Series: Hospital Inpatient Waste Identification Tool Executive Summary Within the US and around the world, hospital executives are facing increasing pressure to reduce operating costs and improve quality of care. Hospitals that fare best will be those that become efficient operators and reduce waste in their clinical care. Efforts are underway in many places to reduce waste, improve efficiency, and maintain quality. In December 2009, the Health Foundation in the United Kingdom commissioned the Institute for Healthcare Improvement (IHI) to design and test a tool for identifying clinical waste within the hospital inpatient setting. Through review of existing literature, conversations with experts, and direct input from hospitals engaged in testing, IHI developed the Hospital Inpatient Waste Identification Tool. The Waste Identification Tool was designed to identify clinical and operational waste from the perspective of frontline clinical staff, with the aim of informing strategic decision making for the hospital. The Hospital Inpatient Waste Identification Tool was developed through two cycles of research and development at IHI. In the first cycle, eight hospitals (six from the UK and two from the US) conducted rapid-cycle testing of the Waste Identification Tool and engaged in one-on-one conference calls with IHI faculty to debrief those tests. The Waste Identification Tool consists of five modules — Ward Module, Patient Care Module, Diagnosis Module, Treatment Module, and Patient Module — that qualitatively identify opportunities for waste reduction. The tool is designed to provide a snapshot of potential areas of waste within a hospital, as identified by frontline clinical staff. Once this snapshot is obtained, representatives of the hospital’s frontline clinical staff, finance department, and leadership engage in a process of enriched review and analysis of Waste Identification Tool findings to prioritize waste reduction initiatives that will result in cost savings for the organization. This white paper describes the Hospital Inpatient Waste Identification Tool, instructs users in how to make best use of it, and offers methods for using Waste Identification Tool findings to inform strategic decisions that will remove waste. Background Impetus for This Work Accelerating health care costs and poor quality have generated headlines in many Western countries in the past few years. Health care expenditures in the United States have tripled, from $714 billion in 1990 to over $2.3 trillion in 2008.1 In the United Kingdom, health care expenditures have risen from 6.6 percent of the gross domestic product (GDP) in 1997 to 8.4 percent of GDP in 2007, reaching upwards of £118 billion, including public and private spending.2 At the same time, the health care quality improvement movement has reached a critical point in terms of reach, public consciousness, provider conscientiousness, and impact on patient care. There have never been so many convergent pressures to improve access and quality with fewer resources. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Yet until very recently, the rationale for health care providers to undertake quality improvement (QI) initiatives rested largely on “doing the right thing,” and any financial benefit resulting from QI efforts was regarded as an attractive side effect. However, impending health care cutbacks and mounting evidence that better care at lower costs can be achieved provide additional motivation for organizations to identify and reduce waste in clinical care processes. In the United Kingdom, the Health Foundation has expressed specific concern about waste that occurs through patient care — for example, waste associated with patient flow (the patient being in the wrong place at the wrong time) and inappropriate care (the patient receiving the wrong treatment). At the request of the Health Foundation and as a natural progression in the Institute for Healthcare Improvement’s (IHI’s) own work on reducing costs and increasing value in health care,3 IHI conducted a research and development initiative aimed at developing and testing a Hospital Inpatient Waste Identification Tool (referred to in this document as the Waste Identification Tool) that frontline staff can use to identify waste within hospitals. This white paper describes how to use the Waste Identification Tool and its findings in a structured and systematic process of identification, prioritization, and reduction of waste in the inpatient hospital setting. Definition of Waste In a broad sense, waste can be considered as any activity or resource in an organization that does not add value to an external customer. Possible examples include wasted materials, movement of people or items from one place to another, inventories, time spent waiting, people working in processes that are not important to the customer, extra steps in a process, repeating work that has been done previously, and more staff than required to match the demand for products and services. Waste identification and reduction has long been a focus for creating efficiency, reducing costs, and improving quality within other industries; carefully targeting waste reduction as a means of reducing costs is now rapidly developing within health care.3 For example, within a hospital setting, patients often spend time waiting to transition to a different level of care. This is most certainly wasted time from the perspective of the patient; it also represents waste for the care providers and the organization. A staffed but empty hospital bed is wasted time for the care providers and wasted expense for the organization. Another example is a hospital-acquired infection. Here the patient’s time is wasted as he/she is likely to undergo additional treatment or have a longer hospital stay; the caregiver’s time is wasted because he/she must provide care that could have been avoided; and the hospital experiences waste as it incurs the added expense of this unnecessary care. The focus on waste as an important strategy for improving the quality of care and reducing costs has increased in recent years. In 2008, the National Priorities Partnership, a partnership between the National Quality Forum and 28 other business and health care organizations within © 2011 Institute for Healthcare Improvement 2 3 Innovation Series: Hospital Inpatient Waste Identification Tool the United States, put forth nine national targets for health care overuse to help create more affordable care.4 In the United Kingdom, the Productive Ward Programme, undertaken by the NHS Institute for Improvement and Innovation, and the NHS Quality, Innovation, Productivity and Prevention (QIPP) activities are examples of efforts to address waste in the delivery of health care. Efforts to reduce waste in the inpatient hospital setting have not progressed in some areas due to inherent conflicts with hospital revenue or failure to recognize the activity as waste. For example, infections that develop during hospitalization have the potential to add revenue under some payment schemes, although from a population health and resource perspective this represents a waste of resources because these infections are potentially preventable. Due to these complexities, the Waste Identification Tool defines waste without reference to revenue. Obviously, some waste adds to cost, some waste adds to revenue, and some waste both adds to cost and detracts from revenue. Because of this variation in financial environments, how waste impacts the hospital’s bottom line must be determined on an organization-specific basis. The academic literature reveals relatively little information about the system-wide or societal perspective of hospital waste. IHI conducted an expanded search of non-academic research — white papers, statements from national research bodies, and reports from consulting firms in the US and the UK — to understand hospital waste priorities. The sources of this information included IHI, the National Quality Forum (NQF), the Agency for Healthcare Research and Quality (AHRQ), and the Institute of Medicine (IOM) in the US, and the NHS Institute for Innovation and Improvement in the UK, among others. The most commonly cited sources of clinical waste (as opposed to administrative or operational waste) were the following: adverse events and complications; inappropriate use of clinical services or providers; overuse of clinical services such as diagnostic procedures, medications, or other treatments; hospital readmissions; lack of care coordination, leading to duplication and rework; unwarranted variation in care when strong scientific evidence exists; and delays. Based on the literature review and a series of key informant interviews, IHI identified three broad categories of clinical waste to provide a structure for initial work in this area: adverse events and complications, inappropriate use of clinical services or providers, and delays in or lack of care coordination. In addition, IHI identified specific markers of these categories of waste and ways they might be identified or reveal themselves on a ward or inpatient unit (e.g., a readmission might be an indicator of either a complication or a lack of care coordination) (see Table 1). Leaders and frontline clinicians strongly recommended that the Hospital Inpatient Waste Identification Tool include the patient and family perspective on unnecessary or unwanted care. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Table 1. Categories of Clinical Waste in the Hospital Setting Category Adverse Events and Complications Inappropriate Use of Clinical Services or Providers Delays in or Lack of Care Coordination Definition Adverse events and complications in an inpatient setting The systematic use of more (or fewer) resources than necessary (e.g., treatment, setting, provider, equipment) Inefficiencies in flow, throughput, communication, and coordination between providers, and between patients, providers, and families Examples • Readmissions • Healthcare-associated infections • Central line infections • Surgical site infections • Ventilator-acquired pneumonias • Procedure-related complications • Adverse drug events • U nwanted end-of-life services • CT scan or MRI instead of an x-ray • Longer than expected length of stay (LOS) • Unnecessary hospitalization • Inappropriate use of antibiotics • • • • of Waste elayed laboratory results D Readmissions Longer than expected LOS Bed held for admission or transfer • Bed held for surgical patient or medical patient • Artificial variability or inappropriate scheduling due to lack of coordination Current Strategies Employed by Hospitals to Reduce Clinical Waste As part of the development of the Hospital Inpatient Waste Identification Tool, IHI conducted a series of interviews with quality leaders across the United States to obtain a better understanding of the current practices in place to reduce waste. Although all of the organizations included in these interviews were addressing waste reduction, their efforts were focused primarily on administrative and operational waste — for example, using Lean tools to create more efficient laboratory or billing practices. Few organizations were reporting success using a waste reduction approach to dealing with clinical inefficiencies. In addition, efforts to reduce waste were not systematic. Projects to reduce cost were conducted in disconnected and unstructured manners; our informants did not have processes or an infrastructure in place for identifying existing waste, nor were they basing strategic priorities for an organizationwide waste reduction effort on the actual financial implications for the organization’s bottom line. © 2011 Institute for Healthcare Improvement 4 5 Innovation Series: Hospital Inpatient Waste Identification Tool Using the Hospital Inpatient Waste Identification Tool Design Principles The Hospital Inpatient Waste Identification Tool was designed to identify waste using a simple, real-time approach. Specifically, the Waste Identification Tool was designed according to the following design principles: • Qualitative Analysis: The purpose of the Waste Identification Tool is to identify and categorize potential waste from the perspective of frontline clinical staff in order to identify strategies for waste reduction and create the engagement necessary for successful implementation of these strategies. This is accomplished through a qualitative assessment of an area or specific patient processes where potential waste is documented as either present or not. The tool does not specify the amount, seriousness, or cause of waste. This is to ensure a simple, non-burdensome process that frontline staff can conduct. • Clear Articulation of Waste Types: Each of the Waste Identification Tool’s modules includes clearly articulated “waste types” — i.e., similar forms of waste that may occur in significant volume and are measurable — and is structured as a one-page worksheet that may be easily understood and used. The one-page worksheet is designed for data to be collected by a frontline reviewer in real time, and also includes a companion instruction page to guide the reviewer’s efforts. Each waste type is intended to be unique to minimize overlap. • Frontline Staff Approach: An essential factor in the development of the Waste Identification Tool is that the waste is identified and data is collected by frontline clinical staff — physicians, nurses, and other clinical staff providing direct patient care. Frontline staff are closest to the work and best positioned to identify potential waste. Given the Waste Identification Tool’s overall objective of identifying waste to inform the organization’s future waste reduction efforts, the engagement of frontline clinical staff helps to ensure successful implementation of waste reduction strategies. Testing IHI initially tested the Hospital Inpatient Waste Identification Tool with participating hospitals between December 2009 and March 2010, beginning with the design and testing of the Ward Module. Initial waste types identified for testing were informed by our original literature reviews and focused on delays and adverse events, including hospital-associated infections and unnecessary hospitalizations. Participating hospitals conducted the first test as a small-scale, proof-of-concept test to determine whether frontline staff could review all beds in a particular ward and, using a simple form with basic definitions, indicate whether the bed was occupied and, if so, whether the patient occupying the bed had experienced an adverse event, an infection, an unnecessary hospitalization, or a delay in care (all forms of waste). Having established that this form of data collection and waste identification was feasible and meaningful to frontline staff, the hospitals testing the tool then focused © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool more closely on refining the identification and definition of the waste types in the Ward Module until sufficient knowledge was acquired. IHI then used a similar process to develop and test additional modules in the Waste Identification Tool. The frontline clinical staff testers of the Waste Identification Tool from the eight participating organizations were, in most cases, nurses and physicians providing direct patient care. The testers used the Waste Identification Tool in a variety of hospital settings, including medical inpatient wards, elective surgery wards, and emergency admissions units. The feedback from frontline testers of the Ward Module informed the development of the subsequent modules. In particular, although the Waste Identification Tool was originally intended to identify clinical waste, there are instances when a waste type could be identified as both operational and clinical. For example, a patient awaiting discharge may be delayed both because of a need for a clinical consult (clinical waste) and because arrangements for transfer have not yet been coordinated (operational waste). Rather than force frontline staff into potentially confusing and disengaging deliberations about definitions of operational versus clinical waste, these distinctions were removed. In addition, testers frequently asked for greater clarity of definitions. Consequently, the IHI team took great care to ensure that definitions were clear to frontline staff and that necessary explanatory detail was easily available within the Waste Identification Tool itself. Testers also consistently requested more concrete examples for each waste type; examples are now included in the Waste Identification Tool as a series of clear bullet points (see Table 1). One of the major issues in developing the Waste Identification Tool centered on the frontline testers’ discomfort and/or perceived inability to deem another clinician’s care or treatment of a patient as inappropriate. In order to maintain the strong engagement of frontline staff in developing and testing the Waste Identification Tool, and to ensure the creation of a resource that would be used by frontline staff going forward, the IHI team decided that reviewers would not be required to make these judgments explicitly. For example, in the Diagnosis Module, users review hospital admission orders for the presence of specific diagnostic tests that often are unnecessary. Rather than ask clinicians to decide on the appropriateness of those tests, reviewers only affirm whether the test (which is often overused) was requested. The Waste Identification Tool then reports the presence or absence of these tests that are often considered wasteful, and signals the need to explore further if they are present in large numbers. As such, decisions related to the appropriateness of care are not made at the point of data collection, but rather through further analysis and conversation taking place with members of the frontline staff, finance, and hospital leadership. Through this process of initial design and testing, the Waste Identification Tool demonstrated strong face-validity with the frontline staff involved in testing the tool. However, utilizing the tool findings obtained by the frontline staff to set priorities and assign resources for successful execution of a waste reduction portfolio of projects requires engagement of other key members of the hospital. To design for this, IHI conducted a second R&D cycle to answer the following questions: © 2011 Institute for Healthcare Improvement 6 7 Innovation Series: Hospital Inpatient Waste Identification Tool 1. Can the Waste Identification Tool be used to stimulate frontline engagement in waste reduction strategies and execution? 2. The Waste Identification Tool has demonstrated face-validity with frontline staff; does it also resonate with hospital leadership? 3. How will hospitals use the information generated through use of the Waste Identification Tool by frontline staff? 4. Can use of the Waste Identification Tool be integrated with ongoing waste reduction strategies? 5. Will the waste reduction strategies result in “dark green dollar” savings (i.e., savings that are realized at the bottom line) for the hospital? 6. How does this method of waste identification and priority setting compare to other successful methods used by hospitals? What are the advantages and disadvantages of the Waste Identification Tool compared to these other approaches? IHI’s testing of the Hospital Inpatient Waste Identification Tool continued with a focus on providing answers to these questions through the design of a process for turning Waste Identification Tool findings into a strategy for reducing waste. We believed that through engagement and productive discussions with frontline staff, finance, and hospital leadership, it would be possible to set strategic priorities, estimate the results, and plan for the successful execution of waste reduction initiatives. Our aim was to further build and test methods that would help hospitals identify, prioritize, and then reduce waste in processes for delivering patient care while improving quality and ultimately reducing expenses for the organization. The specific deliverables for this phase of testing were the following: • T est and document a process of conducting additional analysis of findings from the Waste Identification Tool and determining waste reduction priorities through the engagement of frontline staff, finance, and leadership. • Validate the theory that the Waste Identification Tool is unique in its ability to stimulate frontline staff engagement. • Develop a framework and methods to guide the development and execution of a balanced portfolio of waste reduction projects that result in expense reduction for the hospital. While still an area of learning, the process for moving from waste identified to waste removed begins with analyzing the findings, estimating the impact of waste removed, and using that information to establish priorities for improvement initiatives. Methodology Data collection using the Hospital Inpatient Waste Identification Tool is similar to the process of conducting a point prevalence study: waste is measured at a specific point in time. Measurement is based on a simple analysis as to whether each type of potential waste is assessed as either “yes” © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool (present) or “no” (not present). It is not the goal at this stage to look for mitigating factors or determine the degree or severity of any type of waste; the sole purpose of the Waste Identification Tool is to determine the presence of potential waste at the time of evaluation. This allows insight into the likely prevalence of a given type of waste. Additional information is needed to determine the impact of waste by further investigating its actual prevalence and measuring its financial effect on the organization. After the initial data collection by frontline staff, reviewers measure waste using a simple calculation of percent of beds with waste (i.e., percent of beds or patients with one or more types of waste identified). The denominator varies for each module depending on the unit of measure. It is best to start by conducting a small test of the Waste Identification Tool using only one module. Hospitals often start with the Ward Module and then use additional modules to provide greater understanding of the waste that exists. To begin, identify one or more individuals to conduct the test on one inpatient ward or unit. Use the following as a guiding principle for selecting the individual(s) as the frontline reviewer(s): keep the review as close to the frontline as possible. The Waste Identification Tool was designed to be conducted by those most familiar with the patients and care delivered on the unit or ward being reviewed. In some cases, physicians will need to be considered frontline. In others, the nursing staff is best suited. There will be occasions during which the frontline reviewer(s) will need to obtain additional information from other members of the care team to make an evaluation. It is important that these instances are rare and that most judgments are able to be made by the designated frontline reviewer. As organizations gain experience with the Waste Identification Tool, they will learn which members of their frontline team are best able to serve as reviewers for various modules and waste types. Some organizations have found great value in using multidisciplinary teams for their reviews. If the reviewer is not a direct caregiver on the unit or ward of focus, he/she should complete the test in collaboration with the most appropriate frontline clinical staff member for the patients in the beds being evaluated. The module reviews are easiest and most informative if the reviewers communicate directly with the hospital staff who are most familiar with the patients in those beds. The following process can be used for testing any module: • I dentify an inpatient ward (unit) to review — i.e., any ward that currently has inpatients in designated beds who are receiving care. • Identify a reviewer. The review is best conducted by a mid-level or frontline staff person who is familiar with daily ward care and has a good understanding of medicine. Examples include a nurse, physician, case manager, or knowledgeable mid-level nurse manager or matron. © 2011 Institute for Healthcare Improvement 8 9 Innovation Series: Hospital Inpatient Waste Identification Tool • S elect the appropriate worksheet and instructions for the module you are testing (see Appendix B for Waste Identification Tool worksheets and instructions for each module). The reviewer should visit the ward or unit to assess each item in the worksheet. This should be done in person — not via phone, or by electronic or other remote communication. • For every unit of measure (e.g., patient or bed), place a mark in the appropriate column in the worksheet to indicate that the type of waste listed is present. ❍ The answer as to whether a waste type applies is based on the review occurring at that moment in time. Past events are only applicable if they affect the current status of bed use (e.g., readmission for heart failure would be considered a “yes” in the Unnecessary Hospitalization waste type of the Ward Module for any day of the patient’s stay). ❍ Direct communication is the best method for obtaining some information in some modules; the reviewer should ask those staff caring for the patient directly. Bedside nurses will likely be able to answer many items in the worksheet. The worksheet questions may also be asked of physicians and other clinical staff if they are present at the time of review. Direct communication has enormous value and engages frontline staff in the process. ❍ Review of the case notes or patient record is necessary for obtaining information in some modules or for situations when the bedside nurse is not available. Refer to the instructions for each module for recommendations on sources of information. ❍ In a few cases, it may be necessary to contact additional clinical staff to answer items in the worksheet. This should be rare and it is recommended that reviewers spend limited time contacting others, as this could significantly lengthen the review time and ultimately is not likely to provide value-added information. • Note the number of beds or patients (depending on the module) with any waste identified in the appropriate space on the worksheet. The percentage is calculated as the number of beds or patients, divided by the total number reviewed. • Space is provided in the worksheet to sum the number of each individual waste type (e.g., Healthcare-Associated Infection). This information will be helpful for assessing the impact of a specific waste type on improvement efforts going forward. • When reviews progress to multiple wards or units, use one worksheet per ward or unit. Modules in the Hospital Inpatient Waste Identification Tool Note: All modules, along with instructions and definitions, are included in Appendix B. This section describes in detail each of the modules in the Waste Identification Tool. It is important to note that we encourage organizations to think of each module as contributing key information to a larger “story” about waste that may exist in the organization. After selecting a unit(s) or ward(s) of focus for review with the Waste Identification Tool, hospitals can gain tremendous value in conducting multiple modules on those same unit(s) and ward(s). For example, if reviewers seek to © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool understand the waste that exists on a hospital medical unit, they may want to use both the Patient Care and Treatment Modules. The Patient Care Module might provide evidence that invasive tools (such as urinary catheters) are in use longer than needed by the patient. The Treatment Module might indicate that patients receiving anticoagulants are not getting the treatment indicated in the hospital’s standard protocol. To provide further information, reviewers might use the Patient Module to learn about potential waste from the perspective of the patient. Each module provides a distinct but valuable perspective on opportunities for waste reduction. Ward Module Waste in this module is assessed in hospital geographic areas in which patients are placed into beds for care. This includes the traditional inpatient care areas of medicine and surgery and other locations such as Accident & Emergency (A&E, or the emergency department), admission wards, intensive care, or any holding areas. The primary focus in this module is waste related to bed utilization; thus, for some waste types, only certain events are included. For example, not all healthcare-associated infections, adverse drug events, and procedure complications result in hospital admission or increased length of stay; this module only includes those that do. Because it is not always clearly documented when the hospital stay is lengthened by one of these events, reviewers need to rely on the judgment of those caring for the patient. The denominator for this module is the total number of all beds, including those in use and not in use. Example Table 2 shows an example of a completed Ward Module worksheet (note that the worksheet has been slightly customized by the hospital). In this particular hospital, the Ward Module was tested on four types of units: a trauma surgical intensive care unit, a critical care unit, a cardiovascular intensive care unit, and a burn unit. The primary reviewer, a physician working on these four units, used the Waste Identification Tool on a total of 19 beds. Using the examples provided in the worksheet, if waste was identified as being present for the bed being reviewed, the reviewer reported “yes” and checked the column designating the type of waste. A short but informative description providing a bit more detail on the waste was also included to aid in conversations about future waste reduction efforts. These comments allow the reviewer to include additional detail that will provide further insight into the waste identified — for example, possible trends that may be occurring. The example shows that 16 of the 19 beds had some form of waste, equaling 84 percent waste; moreover, the completed worksheet clearly shows a trend with regard to delays related to end-of-life issues. The worksheet will then be reviewed and discussed by a team of frontline reviewers, members of finance, and hospital leadership to make decisions about what initiatives to put in place to reduce waste in those areas of most prevalence with biggest financial impact for the organization. © 2011 Institute for Healthcare Improvement 10 11 Innovation Series: Hospital Inpatient Waste Identification Tool Table 2. Sample Completed Hospital Inpatient Waste Identification Tool Worksheet: Ward Module Unit: ICU Patient Bed ID Date: April 10 WASTE Yes T-1 X T-2 X T-4 X T-5 X T-7 X T-8 X No Waste Types Nosocomial Infection Adverse Drug Event Procedure Complication Unnecessary Hospitalization Flow Delay Comments Awaiting PICC IR X Lap chole comp X Futility EOL, family X No plan X X X No drip on floor, Pt. walking around ICU X B-S B-T X B-O X X No (insulin) drip on floor X No OR til Friday X Card. Consult, no family meeting, EOL X Pt. fell, No OR til Friday X B-S C-M Clinical Care Delay X T-9 T-10 Reviewer: Physician X X End of Life (EOL) X C-A C-J X V-R X V-A X V-A X V-P X X X X X X Trach Collar trial not done X Awaiting trach & G-Tube X Inf & EOL futility X Pneumothorax & EOL futility Graft inf. & hematoma Total number of beds with any waste identified 16 Percent of total beds reviewed 84 TOTAL BEDS REVIEWED 19 The Waste Identification Tool was designed to be simple to use; in this example, the review was completed in 15 minutes. The provider conducting the review knew the patients well and was familiar with their care. In addition to showing areas where waste may be occurring, this completed worksheet also highlights in actual counts what “frustrates” patients and clinicians on a daily basis. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Patient Care Module In this module, the form of waste captured is unnecessary patient care, particularly treatment that is no longer needed based on changes in patient condition. It includes the following waste types: • • • • • onitoring M Invasive tools Medications Tests Therapies When this module is used, each patient in a bed is assessed to determine if any patient care has been given in the designated waste types that seems to be unnecessary. Very often the care was appropriate when it was initiated for the patient, but was continued longer than necessary. Examples include central lines, prophylactic antibiotics, daily lab tests, and therapies such as physical therapy. Note: This module has had only four tests by frontline staff. When nursing staff complete this module without involvement of physicians and other clinical staff, it seems to be challenging to determine whether the care is needed any longer. A multidisciplinary team may be more effective in conducting reviews for this module. Further testing of this module is warranted. Diagnosis Module At the time of hospital admission, or prior to a surgical procedure, diagnostic tests and procedures may be required to complement a comprehensive history and a complete physical examination. However, the literature suggests that many such tests and procedures are either overused or misused. The Diagnosis Module looks at these types of waste by starting with tests and procedures that are requested as a matter of “routine” on admission or done preoperatively rather than based on the patient’s signs, symptoms, and predicted diagnosis. This module only measures whether common diagnostic tests or procedures were requested or not (“yes” or “no”). Some may have been necessary and appropriate for particular patients, so at this level they are considered as “possible” waste. Further analysis occurring later in the process of utilizing the review findings will be needed to determine the amount of actual waste. This module has two categories of waste types: • H ospital admissions • Preoperative evaluation The review should be conducted on a selected ward or inpatient unit. © 2011 Institute for Healthcare Improvement 12 13 Innovation Series: Hospital Inpatient Waste Identification Tool The following are examples of tests that should be considered as possible waste when requested on admission (i.e., in physician orders at the time of admission and within first 12 hours) or prior to surgery: • • • • • rinalysis U Thyroid function studies Electrocardiogram (ECG) Chest x-ray (CXR) Metabolic panel (typically includes glucose, electrolytes, proteins, kidney function tests, and liver enzymes) Reviewers determine only whether or not the test was requested. Treatment Module The Treatment Module assesses whether treatments supported by scientific evidence are provided, based on an assumption that such treatments will minimize waste resulting from use of other potentially medically unnecessary resources or from complications. Most hospitals apply science to treatment through protocols, guidelines, order sets, or other standardized approaches to care. There is no attempt in this module to validate whether the treatment is appropriate in individual cases. The Treatment Module defines several types of potential waste, using the definitions in the literature and consensus treatment recommendations by expert organizations: • • • • nticoagulation A Glucose management Postoperative treatments for high-volume procedures ❍ Elective hip or knee replacement ❍ Coronary artery bypass graft ❍ Cardiac valve replacement ❍ Femoral-popliteal bypass graft Pain control This is certainly not a comprehensive list, as there are other clinical topics with accepted treatment guidelines backed by science that may be included in future modules or versions. A first assessment using these four areas may provide important insight as to the application and use of standards in a hospital. Early testing of this module has shown some reluctance among the nursing staff to label waste in instances in which the evidence base was not used. Validating that these four types of potential waste are actual waste and expanding the testing are warranted to learn more about this module. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Patient Module The Patient Module is meant to determine what patients perceive as helpful and valuable in their inpatient care. Although most patients do not have the background in health sciences, patients often have significant insight into possible waste that has occurred during their hospitalizations. This module uses a different measurement methodology from the other modules. The Patient Module uses an interview technique to gather qualitative information about possible waste from the patient’s perspective, rather than counting the incidence of potential waste. Example The Patient Module was tested in an interview at one of the test hospitals with a 54-year-old male with recent hip replacement. The patient cited the following specific examples of waste: • A n EKG was done the day of surgery, but had also been done in the internist’s office two days before surgery. • Sequential compression devices kept falling off and never seemed to work. • The physical therapy department continued walking the patient even after he was walking on his own without difficulty. • Portion sizes for meals continued to be large even though the patient requested smaller portions at least three times. Customizing the Hospital Inpatient Waste Identification Tool An important principle during the design of the Hospital Inpatient Waste Identification Tool was to ensure it could be customized to maximize its effectiveness for an organization’s unique setting. Although the Waste Identification Tool has proven to be very useful for hospitals in its original format and as included in this white paper, some organizations may find value in customizing the tool to obtain more specific information about existing waste or to apply the Waste Identification Tool to non-acute care settings. When considering whether to customize the Waste Identification Tool, it is important to keep the following in mind: • C ustomization may focus on any setting, whether inpatient or outpatient (some early testing is even underway to apply the Waste Identification Tool to administrative processes), as long as the frontline approach is used. • The concepts of qualitative evaluation (responding “yes” or “no” to whether waste is present at the time of review) and involving the frontline staff are important. • Clearly identify and define any of the waste types to be considered. © 2011 Institute for Healthcare Improvement 14 15 Innovation Series: Hospital Inpatient Waste Identification Tool The simple customization process is outlined below in three steps. Step 1. Define the Denominator The first step in customizing the Waste Identification Tool is to define the denominator to be used for conducting reviews. Sample denominators include the following: • • • • otal number of beds on a ward or unit T Total number of operating rooms in a hospital Total number of examination rooms in a clinic Any unit of repetitive work (e.g., consecutive MRI scans, physical therapy appointments, or ABGs) Step 2. Articulate and Define the Waste Types Once you have determined your denominator, and based on your knowledge of potential existing waste, articulate the likely waste types to be identified through use of the customized Waste Identification Tool. • C learly define what you consider to be waste for each waste type so that frontline staff conducting the review have no difficulty making a qualitative (“yes” or “no”) decision about whether waste is present. • Use the originally designed modules (Ward, Patient Care, Diagnosis, Treatment, or Patient) as a template when building a worksheet for your customized module and waste types. Step 3. Conduct Tests of the Customized Version To determine whether your customization will obtain the information that is desired and most helpful to you, conduct a small-scale review (on one unit or ward) using the customized module or waste type(s) and then review the information obtained. Testing customized versions of the Hospital Inpatient Waste Identification Tool has only recently begun. However, testing organizations have found customization to be very easy and valuable to their efforts to identify waste. Below are two examples of how the Waste Identification Tool has been customized: • A hospital-based home health agency customized the Waste Identification Tool, creating a new module for use in their Patient Accounts Department with their home care billers. This module is being used to identify waste related to partially paid or denied billing claims. The frontline team, in this case the billers, determined the waste types based on the most common issues encountered and, because of their involvement in the customization process, are very engaged and excited about its use. The customized Waste Identification Tool is located on a shared computer drive within the organization for use as a communication tool and central repository for follow-up notes and © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool resolution. Details ranging from documentation of the denial to follow-up or resolution, as well as tracking of percent of gross revenue denied, are now in one place, eliminating duplicative emails and spreadsheets and allowing for identification of denial trends. • A large health care system customized the Waste Identification Tool for use in its office practices. Based on the Ward Module, the frontline team helped identify waste types appropriate for this setting. A few of the examples of waste types being tested include: exam room contains non-functioning equipment; room used inappropriately; patient in room but physician is not in clinic; patient in room is dilating; patient in room waiting for diagnostic testing; and patient in room longer because initial paperwork is incomplete. Utilization of Hospital Inpatient Waste Identification Tool Findings A Process for Setting Waste Reduction Priorities Once frontline reviewers have obtained sufficient qualitative data from their use of the Waste Identification Tool, they will want to take steps to reduce this waste with the goal of improving the quality and efficiency of care delivered and reducing the overall expense to the organization. The decision regarding the amount of qualitative data to obtain before moving to the next steps in this process is a subjective one. Reviewers should consider how much information is needed to have reasonable confidence that the potential waste identified has a likely impact on the organization. Subsequent quantitative analysis will provide greater understanding of the actual impact of the waste identified. In light of this, exhaustive qualitative data is unnecessary. There is much variation in how hospitals are organized, the services they provide and deliver, and the patients they treat. As a result, the waste types will have different financial and political implications in different hospitals. Hospital leaders will need to understand how each waste type identified with the Waste Identification Tool will affect their hospital in order to prioritize, resource, and implement a portfolio of waste reduction projects. In the 2009 white paper, Increasing Efficiency and Enhancing Value in Health Care,3 IHI outlined specific methods and strategies for developing a waste reduction portfolio of projects that will result in organization-wide savings. Building upon this work, IHI has designed and tested a process for analyzing, prioritizing, and executing waste reduction projects based on the Waste Identification Tool findings. This process is illustrated in Figure 1: • T he left side of Figure 1 shows, from top to bottom, the steps that frontline reviewers take to obtain qualitative data about waste. • Continuing along, the right side of Figure 1 shows, from bottom to top, the steps that leadership then takes to use the findings of the frontline review to analyze, prioritize, and implement waste reduction projects. © 2011 Institute for Healthcare Improvement 16 17 Innovation Series: Hospital Inpatient Waste Identification Tool Figure 1. Hospital Inpatient Waste Identification Tool: The Process of Analyzing, Prioritizing, and Executing Waste Reduction Projects Frontline Evaluation Leadership Evaluation Select Waste Identification Tool Module Implement Waste Reduction Projects Select Ward(s)/ Unit(s) to Review Determine Strategies Tool Instruction Engagement Decision to Resource Conduct Review(s) Understand Financial Impact Potential Waste Identified Conduct Further Analysis Step 1. Analysis • Engagement: Bring together the frontline staff reviewers, one or more members of finance, and hospital leadership to review findings from the Waste Identification Tool and identify two to three types of waste for further investigation. This meeting is called the “conversation”; its purpose is to engage all levels of the organization in a process of understanding the most prevalent or impactful types of waste based on Waste Identification Tool findings. • Conduct Further Analysis and Understand Financial Impact: After identifying two to three priority areas of waste from the initial Waste Identification Tool findings, conduct additional analysis to determine actual prevalence of waste (i.e., through patient case record review) and the financial and political implications of reducing this waste within the specific hospital environment. The financial team should assist with understanding the financial implications and estimating the potential savings. The frontline team should assist with gathering additional quantitative data on the actual prevalence of the waste. In some cases, hospitals have built their confidence in the Waste Identification Tool findings by using it over time. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Step 2. Prioritization • Decision to Resource: After compiling all of the information needed to better understand the impact of reducing waste identified by the Waste Identification Tool, convene the representatives described previously to make a decision about which types of waste to address. This meeting is called the “discussion.” In addition to setting waste reduction priorities using the Waste Identification Tool findings, hospital leadership may also have projects of strategic importance to add to the portfolio. The goal of this process is to develop a portfolio of waste reduction projects that will result in significant cost savings for the hospital. Teams should document anticipated cost savings and the project’s impact on the organization’s bottom line with input from financial leaders.3 As with any successful endeavor, projects selected for waste reduction efforts should have resources committed for execution of those projects. • Determine Strategies: After identifying a portfolio of waste reduction projects based on using the Waste Identification Tool in several areas of the hospital, and in combination with other strategic decision-making processes, the team, including members of the frontline and leadership, should develop strategies for testing changes to reduce waste in selected areas. The users of the Waste Identification Tool are often the strongest advocates for waste reduction projects. Although the goal is organization-wide savings, reduction efforts should begin on a small scale, such as in a specific area of the hospital or with a segment of patients or providers, as is recommended in any improvement initiative. Specific strategies for capturing the actual savings associated with waste reduction efforts are outlined in IHI’s white paper, Increasing Efficiency and Enhancing Value in Health Care: Ways to Achieve Savings in Operating Costs per Year.3 Step 3. Execution • Implement Waste Reduction Projects: Hospital leadership will need to ensure adequate resourcing for successful execution of waste reduction projects and set organizational goals for clinical outcomes and financial savings. Leadership should put into place a process for obtaining this critical frontline input to develop a portfolio of waste reduction projects that will result in year-on-year cost savings. The aim of this process is to engage all key players in identifying waste, setting priorities, and executing a portfolio of waste reduction projects that result in savings for the organization. Waste reduction opportunities may be identified through many different channels. Some projects will be identified by hospital leadership, based on the organization’s strategic priorities. Others may be included because of a specific funding opportunity or because it is of special interest to an influential staff member or clinician. The value of the Hospital Inpatient Waste Identification Tool is that it is a bottom-up approach, enabling frontline staff and middle management to contribute to this process through findings from their use of the Waste Identification Tool. Engagement of the financial team is also critical, as they will help ensure a portfolio of waste reduction projects that will result in © 2011 Institute for Healthcare Improvement 18 19 Innovation Series: Hospital Inpatient Waste Identification Tool significant expense reductions realized at the organization’s bottom line. Organizations working to execute a waste reduction portfolio should set financial goals to drive their efforts. At this time, IHI recommends that an average-sized hospital of approximately 300 beds should aim for a portfolio that results in $10 million in savings in expenditures each year. Example A hospital assembled a team from across multiple medical and surgical units to use the Hospital Inpatient Waste Identification Tool. The team used the Ward Module to understand waste associated with their hospital’s bed utilization. After using the Waste Identification Tool, the team was able to easily identify several areas of waste: unnecessary extended work-up for low-risk chest pain, increased hospital length of stay for sickle cell patients due to an inconsistent plan of care, completion of a full panel of blood tests with every ABG in the ICU setting, delays in consultation recommendations for ICU patients, and delays in testing for inpatients (MRI and CT). The team discussed the potential savings and political implications of conducting projects in each of these areas. The team engaged representatives from finance in this process to help determine savings. Although some projects would not result in significant savings in the current environment, the team decided to include them in a portfolio because of future opportunities for savings. The team involved in determining this set of projects is very excited about bringing their recommendations and data to the hospital leadership team for inclusion in a hospital-wide portfolio of projects. They intend to challenge their senior team to set a financial goal for the organization and to support their routine use of the Waste Identification Tool to contribute to this process. The Hospital Inpatient Waste Identification Tool has been designed in such a way that it may be adapted by individual organizations to maximize its effectiveness within their clinical environment. Organizations may add additional types of waste within modules or use the overall approach to create a new module that addresses a different geographic or functional area. Example A team from one of the test hospitals found the Ward Module to be of great value in identifying, in real time, waste that existed in their ICU. They used the Waste Identification Tool every day over a 30-day period. By doing so, they determined that much of their waste was in clinical delays. This allowed the team to adapt the Ward Module to better meet their needs by further differentiating the types of clinical waste and removing other types of waste that were less prevalent. The hospital staff were thus able to obtain more specific information on areas of most concern and this better informed the process of developing a portfolio of waste reduction projects. In addition, this continuous, real-time approach allowed the nurse manager to discover almost immediately that a new catheter introduced to the unit resulted in significant complications; she was able to discontinue its use within © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool days. Although the Waste Identification Tool findings have not yet been brought to the financial team for further analysis, the nurse manager was able to address an issue that significantly impacted the quality of care delivered to patients on that unit. Additional Resources for Setting Priorities As part of the development of the Waste Identification Tool, IHI designed and tested a matrix to help hospitals prioritize waste reduction initiatives (see Figure 2). The matrix prompts the user to think about each potential project in terms of how much quality will improve and how much cost will be reduced. Although this matrix helps organizations understand the impact of waste reduced within their current financial environment, organizations should explore anticipated changes (such as health care reform) and set priorities based on both the short- and long-term implications for the organization. Figure 2. Waste Reduction Project Portfolio Prioritization Matrix Financial Implications in the Current System Substantial Cost Savings Quality Moderate Cost Savings Cost Neutral, Expense Increase, or Revenue Loss High of Care Implications Low Figure 3 shows an example of a completed matrix. In this example, the team identified five areas of waste in their hospital: hospital-acquired infections, blood culture contamination, handoff confusion, heart failure readmissions, and overuse of lab and x-ray services. For each area of waste, the team made some qualitative estimates about the implications for cost and quality. In this example, reducing hospital-acquired infections (HAIs) seems to have the highest potential to reduce cost and improve quality. Reducing blood culture contamination and improving handoffs are next highest in potential. © 2011 Institute for Healthcare Improvement 20 21 Innovation Series: Hospital Inpatient Waste Identification Tool Figure 3. Sample Completed Waste Reduction Project Portfolio Prioritization Matrix Financial Implications in the Current System Substantial Cost Savings Quality Reduce HospitalAcquired Infections ($7K-$40K per case) High of Care Moderate Cost Savings Cost Neutral, Expense Increase, or Revenue Loss Reduce Blood Culture Contamination ($/patient day) *Reduce Heart Failure Readmissions ($/case) *Reduce Handoff Confusion ($/case) Implications *Decrease Use of Lab and X-ray Services ($/patient day) Low *In the changing health care reform environment, this improvement is likely to have more positive implications for operating revenue and expenses. The hospitals that tested the Waste Identification Tool have found it to be a useful method for identifying waste, setting strategic priorities, and executing a portfolio of projects with the end goal of reducing expense for the hospital (see Figure 4). Figure 4. Establishing a Realistic Portfolio for Waste and Cost Reduction Projects Identify Potential Waste Types Waste, Cost, and Quality Assessment Build and Execute a Portfolio Many methods: •W aste Identification ToolP • Finance engages with potential waste reduction initiatives •S elect initiatives considering goals and environmental realities • Data collection and analysis verifies opportunity •D ashboards •B enchmarking •P lan to capture $ and redeploy •M imic others’ projects P Frontline Staff Engagement © 2011 Institute for Healthcare Improvement • I ntegrate waste initiatives into organizational costs •E xecute on the initiatives with leader support •C apture $ and redeploy Realistic, Effective Portfolio of Waste and Cost Reduction Projects Innovation Series: Hospital Inpatient Waste Identification Tool The Medical Director of one of the hospitals testing the Waste Identification Tool commented: “Our experience with the Waste Identification Tool has demonstrated its value in engaging frontline staff in planning waste reduction activities. When they identify waste, they frequently have ideas about how to eliminate waste. The Waste Identification Tool has also helped us have more substantive discussions between clinical quality people and finance people. As we develop initiatives to decrease costs, we anticipate that the Waste Identification Tool will allow us to avoid across-the-board cuts in favor of cuts targeted to reduce specific waste types.” In this hospital, bedside nurses used the Ward Module to review over 336 beds to gain a snapshot of the potential waste existing in their hospital; they identified waste in 207 beds, or 55 percent. The most prevalent reasons for this waste were the following: rooms were used as storage, beds were waiting to be cleaned, patients were awaiting discharge, and, in several cases, the patient was readmitted from a previous hospitalization. Figure 5 is a bar chart depicting the waste identified in this hospital’s reviews. Figure 5. Waste Identified in One Hospital Using the Hospital Inpatient Waste Identification Tool Ward Module 35 30 Number of Beds 25 20 15 10 5 0 Inappropriate Bed Use HospitalAcquired Infection Procedure Complication Unnecessary Hospitalization Flow Delay Clinical Care Delay Waste Type Identified The result of these reviews was not new news for the nurses involved. However, what was new was their tremendous enthusiasm for the effort because, for the first time, they had been asked to identify the problems for input into the organization’s strategic planning process. The hospital leadership, on the other hand, was very surprised at the magnitude of the waste existing in the hospital. Again, the © 2011 Institute for Healthcare Improvement 22 23 Innovation Series: Hospital Inpatient Waste Identification Tool types of waste discovered was not the surprise, but rather the magnitude of its impact on the organization. In addition, when the leadership team brought these findings to finance, they realized that this information could significantly impact planning underway for new construction in the hospital. In this case, financial planners determined that a single bed in the not-yet-constructed facility had a value of about $1M. With 55 percent of the beds in the current hospital already considered to include waste, according to the Waste Identification Tool findings, it was clear that the organization could potentially save millions if efforts were made to reduce waste appropriately. Conclusion The Hospital Inpatient Waste Identification Tool helps hospital staff and leaders with the systematic identification of clinical and operational waste and subsequent priority setting of waste reduction initiatives that will result in cost savings for the organization. IHI developed and tested the Waste Identification Tool with direct input from hospital frontline clinical staff and leaders. Teams have used the Waste Identification Tool to identify potential and actual waste in five areas comprising 20 waste types. Frontline staff indicate that the Waste Identification Tool is easy to use and to teach to other staff members. Leaders report that use of the Waste Identification Tool ensures engagement of their workforce in waste reduction efforts, melting resistance to change and creating a formal process for waste identification and reduction that can result in real bottom-line savings. Hospitals can use the Waste Identification Tool as one key strategy in an ongoing process of identifying, assessing the impact of, and reducing waste by engaging both frontline staff and leadership. The design of the Waste Identification Tool lends itself to adaptation by individual organizations to ensure its value within the specific environment of that hospital. IHI looks forward to learning more about the most effective strategies for identifying, prioritizing, and reducing waste through greater use of the tool over time. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool References The Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Care Expenditure Data. January 2010. Available at: http://www.cms.gov/nationalhealthexpenddata/01_overview.asp. 1 2 K Centre for the Measurement of Government Activity. Expenditure on Health Care in the UK. April 2009. U Available at: http://www.statistics.gov.uk/articles/nojournal/Expenditure-on-health-09.pdf. 3 artin LA, Neumann CW, Mountford J, Bisognano M, Nolan TW. Increasing Efficiency and Enhancing Value M in Health Care: Ways to Achieve Savings in Operating Costs per Year. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at: http://www.ihi.org/IHI/Results/ WhitePapers/IncreasingEfficiencyEnhancingValueinHealthCareWhitePaper.htm. 4 ational Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s N Healthcare. Washington, DC: National Quality Forum; 2008:47. Appendices Appendix A: Frequently Asked Questions about the Hospital Inpatient Waste Identification Tool Appendix B: Hospital Inpatient Waste Identification Tool: Worksheets and Instructions for Five Modules • • • • • ard Module W Patient Care Module Diagnosis Module Treatment Module Patient Module © 2011 Institute for Healthcare Improvement 24 25 Innovation Series: Hospital Inpatient Waste Identification Tool Appendix A: Frequently Asked Questions about the Hospital Inpatient Waste Identification Tool Q: Most recent reports list misuse and overuse as key areas of waste. Why are these types of waste not represented in the Waste Identification Tool? A: Misuse and overuse are commonly identified by experts during retrospective review of specific resource utilization (such as MRIs) or with specific types of diseases and patients. The Hospital Inpatient Waste Identification Tool was designed specifically not to place frontline staff in the position of having to judge the validity of another clinician’s decision; instead, it leaves this determination to the experts performing the enriched review that occurs later. Q: Can we add waste types to the Waste Identification Tool? A: Yes. The waste types identified and defined in the Waste Identification Tool are based on commonly observed waste types in most hospitals, but will not be observed equally in all hospitals. We encourage the addition of waste types that reflect the unique nature of your ward or hospital. The best way to add waste types is to clearly define the type of waste you wish to identify and then do a simple objective review as to whether or not it is present. Q: We had several different people survey the same ward (unit) and they came up with different percentages of waste. Should we be worried about variation in the waste data? A: No. The first step in using the Waste Identification Tool is to obtain the frontline staff perspective — the person completing the worksheet for the selected tool module. Each reviewer will interpret waste based on his/her experience and knowledge. Since the purpose of the initial evaluation using this Waste Identification Tool is to start the dialogue about whether waste types warrant improvement efforts, this type of variation is expected. Use the tool review findings as an opportunity for learning: meet with the reviewers and discuss the differences and how they reached their conclusions. This may help identify opportunities to clarify the instructions or add criteria that may be helpful during future reviews. Q: How does the Waste Identification Tool differ from the current way leadership looks at waste in the hospital? A: Most efforts at waste reduction often focus on budget reductions because volume, staffing, and finances are easy to measure. The Waste Identification Tool instead uses the perspective of frontline staff to identify opportunities to change the way work occurs, rather than just eliminate services. By engaging frontline staff in the identification of waste, the prediction is that there will be greater staff support for changes to reduce waste and ultimately these changes will lead to better care for patients and improved finances for the hospital. © 2011 Institute for Healthcare Improvement Innovation Series: Hospital Inpatient Waste Identification Tool Q: As a hospital leader, it seems unlikely to me that the frontline staff really have insight as to which types of waste will have an economic impact on hospital cost. How can the frontline reviews actually lead to money saved? A: Generally, the best people to identify waste are those actually doing the work. Given the correct tools and permission to label work or outcomes as “waste,” the frontline staff who tested the Waste Identification Tool demonstrated that this process works quite well. However, they are not in a position to quantify the actual cost savings that might be realized from waste reduction efforts; that is the reason that finance personnel and leadership must be involved in these efforts. The frontline reviews alone using this Waste Identification Tool will not lead to money saved. The dialogue between frontline staff, leadership, and finance can lead to changes that will. © 2011 Institute for Healthcare Improvement 26 27 Innovation Series: Hospital Inpatient Waste Identification Tool Appendix B: Hospital Inpatient Waste Identification Tool: Worksheets and Instructions for Five Modules The Hospital Inpatient Waste Identification Tool includes five modules; the worksheets and instructions for the five modules follow in this section. • • • • • ard Module: Worksheet and Instructions W Patient Care Module: Worksheet and Instructions Diagnosis Module: Worksheet and Instructions Treatment Module: Worksheet and Instructions Patient Module: Worksheet and Instructions The worksheet for each module is intended to be used by a frontline provider for data collection in real time. The worksheets and instructions for each module are designed to be printed as one two-sided document. © 2011 Institute for Healthcare Improvement Yes No WASTE* Bed Empty & Staffed © 2011 Institute for Healthcare Improvement __________ __________ __________ Percent of total beds reviewed TOTAL BEDS REVIEWED HealthcareAssociated Infection Adverse Drug Event Procedure Complication Unnecessary Hospitalization Flow Delay Clinical Care Delay Comments Reviewer(s): _____________________________________ Hospital Inpatient Waste Identification Tool Total number of beds with any waste identified Bed Occupied or Used Inappropriately Waste Types Date & Time of Review: ______________ Bed Empty & Not Staffed *If any waste type is checked, note YES for waste. TOTALS Patient Bed ID Ward/Unit: _________________________ Hospital Inpatient Waste Identification Tool Worksheet: Ward Module Innovation Series: 28 © 2011 Institute for Healthcare Improvement Adverse Drug Event: Drug-caused admission or extension of stay • Anticoagulant bleeding • Dialysis secondary to drug toxicity • Bone marrow depression • Dehydration • Arrythmia • Other Healthcare-Associated Infection: Patient admitted or treated for an infection caused by medical care • Ventilator-associated pneumonia (VAP) •M ethicillin-resistant Staphylococcus aureus (MRSA) • C. difficile • Bloodstream infection • Urinary tract infection (UTI) • Wound infection • Other EXAMPLES OF WASTE or POTENTIAL WASTE to INCLUDE Bed Occupied or Used Inappropriately: Beds used for other than inpatient care • Temporary storage • Temporary offices • Outpatient use Clinical Care Delay: Delays in the delivery of clinical care that result in the patient remaining in a bed • Imaging procedures not able to be done or delayed •S urgery delays due to tests or consults not completed •C onsultation delays resulting in prolonged stay Flow Delay: Delays causing beds to be occupied that should not be •P atient in a bed with a completed discharge waiting to leave •B ed being held for any type of patient — medical, surgical, admission, or transfer •E xpired patient in the bed awaiting transfer to morgue (this prevents other admissions) •R oom not cleaned or in the process of being cleaned (this may delay patients who are waiting for bed assignments) Unnecessary Hospitalization: Any hospitalization where a defect in care caused the readmission or admission •D iabetes •H eart failure •H ypertension •C hronic obstructive pulmonary disease •A dult asthma •P neumonia •U rinary tract infection •U nplanned readmission •O ther Procedure Complication: Any procedure complication causing admission or extension of stay • Intra-operative complication •P neumothorax •H ematoma •P ostoperative shock, myocardial infarction, renal failure •O ther Innovation Series: Direct communication with bedside caregivers is recommended for this module. Use review of case notes or patient records only for information that cannot be obtained or if bedside caregivers are not available. INSTRUCTIONS Determine the number of beds for the ward or unit. This should be the total number of all beds, including those in use and not in use. Each bed should be noted on the worksheet in the “Patient Bed ID” column, noting each bed with an identification that will be understood locally (for example, room numbers, ward bed numbers, or other identifications typically used on the ward). Use a second worksheet if you need additional space to review all beds on the ward or unit. Note the number of total beds reviewed in the space for “Total Beds Reviewed.” Ward Module Instructions 29 Hospital Inpatient Waste Identification Tool Yes No WASTE* Monitoring © 2011 Institute for Healthcare Improvement __________ __________ TOTAL PATIENTS REVIEWED Tests Therapies Comments Reviewer(s): _____________________________________ Hospital Inpatient Waste Identification Tool Percent of patients with waste identified Total number of patients with any waste identified __________ Medications Waste Types Date & Time of Review: ______________ Invasive Tools *If any waste type is checked, note YES for waste. TOTALS Patient Bed ID Ward/Unit: _________________________ Hospital Inpatient Waste Identification Tool Worksheet: Patient Care Module Innovation Series: 30 © 2011 Institute for Healthcare Improvement EXAMPLES OF WASTE or POTENTIAL WASTE to INCLUDE Monitoring: Any forms of monitoring that are no longer necessary or are being used or completed more frequently than necessary, such as unneeded monitoring or use of monitoring device (this does not include standard vital sign measurements) • T elemetry •P ulse oximetry •C apnography •N euro checks •C apillary glucose checks •O ther Therapies: Any form of therapy that may have been appropriate when initiated but is no longer necessary or not necessary at the same frequency •P hysical •S peech •O ccupational •R espiratory Tests: Consider whether laboratory tests are still helpful •O rders for daily laboratory tests (e.g., glucose) • T ests being repeated because results were invalid, or specimen was lost or unusable Medications: Consider whether all medications are still needed and at same route and frequency, particularly those that were initiated during hospitalization •A ntibiotics •P ain medications •O ther Invasive Tools: Consider whether any invasive device is unneeded •C entral lines •P eripheral IV lines •C hest tubes •D rains •A rterial lines •U rinary catheter •O ther Innovation Series: Direct communication with bedside caregivers is recommended for this module. Use review of case notes or patient records only for information that cannot be obtained or if bedside caregivers are not available. INSTRUCTIONS Review each patient. Use the “Patient Bed ID” column to note an identification that will be understood locally (e.g., room numbers, ward bed numbers, or other identifications typically used on the ward or unit). Use a second worksheet if you need additional space. Note the number of total patients reviewed in the space at bottom of worksheet. Unoccupied beds are not used in this module. Patient Care Module Instructions 31 Hospital Inpatient Waste Identification Tool © 2011 Institute for Healthcare Improvement Comments Metabolic Panel Hospital Inpatient Waste Identification Tool Comments __________ TOTAL PATIENTS REVIEWED __________ CXR TOTAL PATIENTS REVIEWED ECG __________ Thyroid Function Percent of patients with waste identified Urinalysis __________ Patient Bed ID Percent of patients with waste identified Metabolic Panel Total number of patients with any waste identified __________ CXR Total number of patients with any waste identified __________ ECG Reviewer(s): ________________________________________ Reviewer(s): ________________________________________ Thyroid Function Date & Time of Review: _______________________________ Date & Time of Review: _______________________________ Urinalysis Ward/Unit: _________________________________________ Ward/Unit: _________________________________________ Patient Bed ID Preoperative Evaluation Waste Types (Surgical Ward or Unit) Hospital Admissions Waste Types (Medical Ward or Unit) Hospital Inpatient Waste Identification Tool Worksheet: Diagnosis Module Innovation Series: 32 © 2011 Institute for Healthcare Improvement 3. Determine whether any of the five tests were requested. Do not attempt to validate why the tests were ordered. 2. Preoperative Evaluation: On a surgical ward or inpatient unit, review the case notes or patient record for surgical patients (preop or post-op) and determine if these five tests were completed during preoperative evaluation, either in an outpatient setting or as part of inpatient pre-operative testing. 1. Hospital Medical Admissions: On any medical ward or inpatient unit, review the case notes or patient record for each patient and evaluate only the initial admission orders — those initiated in Accident & Emergency (Emergency Department), admission unit, or within the first 12 hours since decision to admit. EXAMPLES OF WASTE or POTENTIAL WASTE to INCLUDE The following tests should be considered as possible waste when requested on admission (in physician orders at time of admission and within first 12 hours) or prior to surgery. Reviewers only determine whether or not the test was requested. • Urinalysis • Thyroid function studies • Electrocardiogram (ECG) • Chest x-ray (CXR) •M etabolic panel (typically includes glucose, electrolytes, proteins, kidney function tests, and liver enzymes) Innovation Series: Case note or patient record review will be necessary for this module. INSTRUCTIONS Review each patient. Use the “Patient Bed ID” column to note an identification that will be understood locally (e.g., room numbers, ward bed numbers, or other identifications typically used on the ward or unit). Use a second worksheet if more space is needed. Note the number of total patients reviewed in the space at bottom of worksheet. Unoccupied beds are not used in this module. Diagnosis Module Instructions 33 Hospital Inpatient Waste Identification Tool __________ __________ __________ Total number of patients not on standards Total number of patients where no standard exists Not on standard No standard exists Glucose Management On standard Total number of patients on standards No standard exists __________ Not on standard Anticoagulation On standard Total number of patients assessed for standards Patient Bed ID Not on standard No standard exists On standard Not on standard No standard exists Pain Control Reviewer(s): _____________________________________ Postoperative Care On standard Date & Time of Review: ______________ Refer to instructions for information on which patients to include. Ward/Unit: _________________________ Hospital Inpatient Waste Identification Tool Worksheet: Treatment Module Innovation Series: Hospital Inpatient Waste Identification Tool © 2011 Institute for Healthcare Improvement 34 © 2011 Institute for Healthcare Improvement If treatment plans vary by clinician, such as each surgeon or group of surgeons with a protocol or order set for their patients, this does not represent a standard. In such cases select “no standard exists.” To be considered a “standard” there must be one treatment plan designed for most patients, regardless of the physician caring for the patient. Do not attempt to determine if the use or non-use of a protocol is appropriate. Determine if a standard protocol or pathway is being used. No standard exists — There is no standard. *Select this answer if there is a standard for this treatment but not for this type of patient. For example, if an anticoagulation standard exists that is used only for medical patients but you are reviewing a surgical patient, select “no standard exists.” Not on standard — A hospital standard exists, but documentation indicates that it is not being used for the patient’s care. DEFINITIONS On standard — Patient is receiving care according to the standard. Innovation Series: Do not review patients who are not in these categories. INSTRUCTIONS Select a ward or unit and identify the following types of patients for review: 1. Receiving anticoagulants 2. Receiving insulin 3. Postoperative for: a) E lective hip or knee replacement b) Coronary artery bypass graft c) Cardiac valve replacement d) Femoral-popliteal bypass graft 4. Receiving pain control (for any reason — oncology, post-op, chronic pain, etc.) Treatment Module Instructions 35 Hospital Inpatient Waste Identification Tool Hospital Inpatient Waste Identification Tool © 2011 Institute for Healthcare Improvement **“Harm” is defined as unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization. 4. Did you have any test or procedure that caused you harm**? _____NO _____YES If yes, what? 3. Did you wait longer than expected for anything during your stay (such as a test, procedure, consultation, or results)? _____NO _____YES If yes, what? 2. Was there anything during your hospital stay (such as treatments, tests, or professional visits) that you received or occurred that was not helpful to your recovery, or hindered your recovery? _____NO _____YES If yes, what? 1. Do you feel you could have been discharged home sooner? _____NO _____YES If yes, why? QUESTIONS: Patient Reference*: ________________________________________ *Optional — Note a reference number to patient if notes or record may be reviewed later. Ensure compliance with privacy and confidentiality policies. Ward/Unit: _________________________ Date & Time of Review: ____________________ Reviewer(s): __________________________ Hospital Inpatient Waste Identification Tool Worksheet: Patient Module Innovation Series: 36 Record some brief notes with the patient’s comments and perspectives in the worksheet. Only interview patients who are willing to participate. Innovation Series: Be sure to inform patients as to what information will be noted and how it will be used. First explain the purpose of the interview and obtain permission. Identify five adult patients scheduled for discharge to the home setting and who are capable of participating in a brief interview. Patient Module Instructions 37 Hospital Inpatient Waste Identification Tool © 2011 Institute for Healthcare Improvement White Papers in IHI’s Innovation Series 1 Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates 2 Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings 3 The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement 4 Improving the Reliability of Health Care 5 Transforming Care at the Bedside 6 Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition) 7 Going Lean in Health Care 8 Reducing Hospital Mortality Rates (Part 2) 9 Idealized Design of Perinatal Care 10 Innovations in Planned Care 11 A Framework for Spread: From Local Improvements to System-Wide Change 12 Leadership Guide to Patient Safety 13 IHI Global Trigger Tool for Measuring Adverse Events (Second Edition) 14 Engaging Physicians in a Shared Quality Agenda 15 Execution of Strategic Improvement Initiatives to Produce System-Level Results 16 Whole System Measures 17 Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives 18 Using Evidence-Based Environmental Design to Enhance Safety and Quality 19 Increasing Efficiency and Enhancing Value in Health Care: Ways to Achieve Savings in Operating Costs per Year 20 Reducing Costs Through the Appropriate Use of Specialty Services 21 Respectful Management of Serious Clinical Adverse Events 22 The Pursuing Perfection Initiative: Lessons on Transforming Health Care 23 Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 2 24 3 Hospital Inpatient Waste Identification Tool All white papers in IHI’s Innovation Series are available online at www.ihi.org and can be downloaded at no charge. 20 University Road, 7th Floor • Cambridge, MA 02138 • (617) 301-4800 • www.IHI.org Pocket Guide Team Strategies & Tools to Enhance Performance and Patient Safety Table of Contents TeamSTEPPS® • Framework and Competencies…..4 • Key Principles…………………………..5 Team Structure • Multi-Team System For Patient Care………………………………………..7 Communication • SBAR………………………………………9 • Call-Out…………………………………10 • Check-Back……………………………11 • Handoff………………………………….12 • “I PASS THE BATON”……………..13 Leadership • Effective Team Leaders……………15 • Team Events…………………………..16 • Brief Checklist………………………..17 • Debrief Checklist…………………….18 2 Table of Contents Situation Monitoring • Situation Monitoring Process……20 • STEP…………………………………….21 • Cross-Monitoring…………………….23 • I’M SAFE Checklist………………….24 Mutual Support • Task Assistance…………………… 26 • Feedback……………………………….27 • Advocacy and Assertion………… 28 • Two-Challenge Rule………………..29 • CUS………………………………………30 • DESC Script…………………………31 Team Performance Observation Tool………………………………………………32 Barriers, Tools and Strategies, and Outcomes……………………………….33 Contact Information ……………………….35 3 Framework and Competencies Team Competency Outcomes Knowledge • Shared Mental Model Attitudes • Mutual Trust • Team Orientation Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety TeamSTEPPS has five key principles. It is based on team structure and four teachable-learnable skills: Communication, Leadership, Situation Monitoring, and Mutual Support. The arrows depict a two-way dynamic interplay between the four skills and the team-related outcomes. Interaction between the outcomes and skills is the basis of a team striving to deliver safe, quality care and support quality improvement. Encircling the four skills is the team structure of the patient care team, which represents not only the patient and direct caregivers, but also those who play a supportive role within the health care delivery system. …TeamSTEPPS is an evidence-based framework to optimize team performance across the health care delivery system. 4 Key Principles Team Structure Identification of the components of a multi-team system that must work together effectively to ensure patient safety Communication Structured process by which information is clearly and accurately exchanged among team members Leadership Ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources Situation Monitoring Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning Mutual Support Ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload 5 Team Structure Multi-Team System For Patient Care Safe and efficient care involves the coordinated activities of a multi-team system. MTS PATIENT CONTINGENCY TEAMS CORE TEAM COORDINATING TEAM ANCILLARY & SUPPORT SERVICES ADMINISTRATION 7 Team Structure Communication SBAR A technique for communicating critical information that requires immediate attention and action concerning a patient’s condition Situation – What is going on with the patient? “I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new onset.” Background – What is the clinical background or context? “Patient is a 62-year-old female postop day one from abdominal surgery. No prior history of cardiac or lung disease.” Assessment – What do I think the problem is? “Breath sounds are decreased on the right side with acknowledgment of pain. Would like to rule out pneumothorax.” Recommendation and Request – What would I do to correct it? “I feel strongly the patient should be assessed now. Can you come to room 251 now?” 9 Communication Communication Call-Out Strategy used to communicate important or critical information • Informs all team members simultaneously during emergent situations • Helps team members anticipate next steps • Important to direct responsibility to a specific individual responsible for carrying out the task Example during an incoming trauma: Leader: “Airway status?” Resident: “Airway clear” Leader: “Breath sounds?” Resident: “Breath sounds decreased on right” Leader: “Blood pressure?” Nurse: “BP is 96/62” 10 Check-Back Using closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended The steps include the following: 1. Sender initiates the message 2. Receiver accepts the message and provides feedback 3. Sender double-checks to ensure that the message was received Example: Doctor: “Give 25 mg Benadryl IV push” Nurse: “25 mg Benadryl IV push” Doctor: “That’s correct” 11 Communication Communication Handoff The transfer of information (along with authority and responsibility) during transitions in care across the continuum. It includes an opportunity to ask questions, clarify, and confirm. Examples of transitions in care include shift changes; transfer of responsibility between and among nursing assistants, nurses, nurse practitioners, physician assistants, and physicians; and patient transfers. 12 Handoff Strategy designed to enhance information exchange during transitions in care “I PASS THE BATON” I Introduction Introduce yourself and your role/job (include patient) P Patient Name, identifiers, age, sex, location A Assessment Present chief complaint, vital signs, symptoms, and diagnoses S Situation Current status/circumstances, including code status, level of (un)certainty, recent changes, and response to treatment S Safety Concerns Critical lab values/reports, socioeconomic factors, allergies, and alerts (falls, isolation, etc.) B Background Comorbidities, previous episodes, current medications, and family history A Actions Explain what actions were taken or are required. Provide rationale. T Timing Level of urgency and explicit timing and prioritization of actions O Ownership Identify who is responsible (person/team), including patient/family members N Next What will happen next? Anticipated changes? What is the plan? Are there contingency plans? THE 13 Communication Leadership Effective Team Leaders The following are responsibilities of effective team leaders: • Organize the team • Identify and articulate clear goals (i.e., the plan) • Assign tasks and responsibilities • Monitor and modify the plan; communicate changes • Review the team’s performance; provide feedback when needed • Manage and allocate resources • Facilitate information sharing • Encourage team members to assist one another • Facilitate conflict resolution in a learning environment • Model effective teamwork 15 Leadership Leadership Team Events Sharing the Plan • Brief – Short session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies Monitoring and Modifying the Plan • Huddle – Ad hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan Reviewing the Team’s Performance • Debrief – Informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors 16 Brief Checklist During the brief, the team should address the following questions: †† Who is on the team? †† Do all members understand and agree upon goals? †† Are roles and responsibilities understood? †† What is our plan of care? †† What is staff and provider’s availability throughout the shift? †† How is workload shared among team members? †† What resources are available? 17 Leadership Leadership Debrief Checklist The team should address the following questions during a debrief: †† Was communication clear? †† Were roles and responsibilities understood? †† Was situation awareness maintained? †† Was workload distribution equitable? †† Was task assistance requested or offered? †† Were errors made or avoided? †† Were resources available? †† What went well? †† What should improve? 18 Situation Monitoring Situation Monitoring Situation Monitoring Process Situation monitoring is the process of continually scanning and assessing a situation to gain and maintain an understanding of what’s going on around you. Situation awareness is the state of “knowing what’s going on around you.” A shared mental model results from each team member maintaining situation awareness and ensures that all team members are “on the same page.” 20 STEP A tool for monitoring situations in the delivery of health care Components of Situation Monitoring: 21 Situation Monitoring Situation Monitoring STEP Tool to help assess health care situations Status of Patient Patient History Vital Signs Medications Physical Exam Plan of Care Psychosocial Issues Team Members Fatigue Workload Task Performance Skill Stress Environment Facility Information Administrative Information Human Resources Triage Acuity Equipment Progress Toward Goal Status of Team’s Patient(s)? Established Goals of Team? Tasks/Actions of Team? Plan Still Appropriate? 22 Cross-Monitoring A harm error reduction strategy that involves: • Monitoring actions of other team members • Providing a safety net within the team • Ensuring that mistakes or oversights are caught quickly and easily • “Watching each other’s back” 23 Situation Monitoring Situation Monitoring Each team member is responsible for assessing his or her own safety status I’M SAFE Checklist †† I = Illness †† M = Medication †† S = Stress †† A = Alcohol and Drugs †† F = Fatigue †† E = Eating and Elimination 24 Mutual Support Mutual Support Task Assistance Helping others with tasks builds a strong team. Key strategies include: • Team members protect each other from work overload situations • Effective teams place all offers and requests for assistance in the context of patient safety • Team members foster a climate where it is expected that assistance will be actively sought and offered 26 Feedback Information provided to team members for the purpose of improving team performance Feedback should be: • Timely – given soon after the target behavior has occurred • Respectful – focuses on behaviors, not personal attributes • Specific – relates to a specific task or behavior that requires correction or improvement • Directed toward improvement – provides directions for future improvement • Considerate – considers a team member’s feelings and delivers negative information with fairness and respect 27 Mutual Support Mutual Support Advocacy and Assertion Advocate for the patient • Invoked when team members’ viewpoints don’t coincide with that of the decisionmaker Assert a corrective action in a firm and respectful manner • Make an opening • State the concern • State the problem (real or perceived) • Offer a solution • Reach agreement on next steps 28 Two-Challenge Rule Empowers all team members to “stop the line” if they s…
Purchase answer to see full attachment