A Case Study on SharedCare
Across the nation, hospitals are re-evaluating their care delivery models to increase quality, safety, efficiency and affordability. New Hanover Regional Medical Center in Wilmington, North Carolina, a 769-bed teaching hospital, was meeting quality goals and maintaining an impressive operating margin, however it became evident that the current primary delivery of care model would not be able to support the long-term strategic goals. This case study examines how the organization applied Lean methodology to redesign and launch a new team nursing model.
To prepare the organization to successfully deliver high-value, accountable care to the community, the organization embarked on a cultural transformation by making a commitment to use Lean methodology.
Feedback from patients indicated that their expectations in regard to communication and responsiveness to their needs were not always met by patient care staff and clinicians. Additionally, nursing staff were highly frustrated with interruptions in workflow and the mounting number of tasks that prevented them from spending time at the bedside with patients and practicing at the top of their license. Patients rated “responsiveness of staff” at 2 percent and the fall rate on the most challenged medical unit was 7.5 per 1000 patient days – more than double the acceptable goal. RN turnover rates were greater than 20 percent with no sign of decline.
Executive leadership speculated that traditional top-down management driven process improvement initiatives were unlikely to result in long-term change and that any change in care delivery would require overwhelming buy-in and enthusiasm from frontline patient care staff. As a result, the bold decision was made to put the creative power in the hands of the patient care staff with the task being to recreate a care delivery model, using Lean methodology, that would not only meet the quality, safety and clinical needs of the patients and staff, but would be financially sustainable for the foreseeable future.
Identifying and Examining the Issues
The journey to redefine the model of care began by developing a current state value stream map (VSM) of the inpatient medical-surgical care delivery model from the time of admission through the discharge phase of the patient’s hospitalization. In order to capture the amount and type of work provided to patients, a collaborative group of stakeholders consisting of staff nurses, nursing managers, case managers, physicians, nursing assistants, physical therapists, dietitians, pharmacists and patients was assembled.
Their charge during a week-long improvement event was to identify the step-by-step patient care processes within the adult inpatient medical-surgical patient care units to understand how the work actually occurred. The team created a VSM of the path the patient took from the beginning to the end of hospitalization in order to identify the interconnectedness of care delivery processes and identify waste within the care delivery model.
After the VSM was created by the team, participants observed seven different medical-surgical units. The goal was to gain an understanding of issues within the care delivery model from both patient and staff perspectives. Patients were interviewed about their experiences while staff were asked to identify what prevented them from easily, safely and efficiently completing their work.
Major waste themes included fragmented communication between disciplines, unclear and poorly communicated plans of care, constant interruptions during care delivery, compartmentalized work practices by all disciplines and a lack of top-of-license practice. Waste identified across the VSM confirmed ample opportunity to create a different and better way to work that would benefit patients, clinicians and the organization.
Creating a Better Way to Work: A New Care Model
The team was challenged to conceptualize an ideal, waste-free way to provide healthcare to patients in the future. Improvements in care delivery were captured on a future state VSM. The team realized standardized processes would be necessary and that there was no longer a place for variation based on personal preferences. Individual care providers practicing within silos prevented effective communication between care providers and with patients. Major countermeasures included:
- Care provided by teams of nurses and nursing assistants with defined roles and responsibilities.
- Frequent, standardized communication huddles to ensure that patient care was coordinated and communicated clearly between all disciplines of the team.
- Mechanisms to identify when staff were overloaded and needed assistance.
The team believed the new model, dubbed SharedCare, would result in an increase in the quality of care delivered to patients, improved communication between care teams and patients and improved patient satisfaction scores. The proposed future state also would create an environment where work was equitable, manageable and satisfying for staff.
The SharedCare model was tested using multiple PDSA (Plan, Do, Study, Act) trials. These iterative PDSA trials, or small cycles of change, provided the opportunity to test the proposed countermeasures to determine if the process changes resulted in the improved outcomes the team had hypothesized. The initial trials involved one to two nurses and their nursing assistants with their assigned group of patients. Over a three month period, the model underwent numerous iterations and adjustments before successful implementation on the entire medical-surgical hospitalist unit.
Applying Key Lean Concepts
The SharedCare model was built on a foundation of standardized work created by direct patient care staff. Identifying roles and responsibilities within the new nursing team model was essential as it required a different mindset from the primary nursing model. Clear role delineation outlined in a standardized work document helped staff perform the right work at the right time for each patient. It also increased the opportunity for staff to work consistently at the top of their license and reduced the number of interruptions care providers experienced. Standardized work also provided a mechanism for structured communication for team huddles to occur three times during every 12 hour shift. During each huddle, specific key points are addressed to ensure that all team members have pertinent patient information throughout the shift, that patient specific goals and plans of care are identified and achieved, and that there is successful loop closure of delegated tasks or escalation of patient related issues well before the end of the shift. Huddles, guided by standardized work, created communication connections that were lacking in the previous model of care.
Standardized bedside handoff processes also were created. The standardized nursing shift report ensures that relevant and pertinent information is always exchanged between off-going and oncoming nurses. Information is organized so that nurses participate in a standardized process that thoroughly and efficiently captures key quality and safety concerns, patient specific goals and discharge planning information. While at the bedside, the nurses update the patient’s Roadmap to Discharge so the patient is aware of the plan for the day and has the opportunity to provide information or ask questions.
Including andons in the SharedCare model has created a safe way for staff members to verbally identify when their current workload has exceeded their ability to complete work in a safe or timely manner while encouraging staff to indicate that they need assistance. Multiple times throughout the shift, staff declare their current workload status as green, yellow or red. Green indicates the staff member is caught up with all work and has the ability to help other staff members if needed. Yellow identifies a staff member who is able to complete his or her own work but is unable to assist another team member, while red signifies a team member in need of assistance. The use of andons has promoted direct and clear communication between staff members and has helped foster a culture of teamwork and camaraderie.
Applying Lean Leadership to Sustainment
The shift to the new care model has been a cultural change for patient care staff and has required nursing unit leaders to work differently as well. Sustainability of SharedCare has been achieved through the use of Lean Management System (LMS) tools including a unit based huddle board and a verification and validation process to monitor standardized work. The unit huddle board focuses the staff’s attention on the unit’s plan of the day, including any safety, equipment or workflow issues. The huddle board also promotes the exchange of dialogue about progress with current unit based problem solving initiatives. SharedCare units track unit specific daily indicators that align with organizational strategic goals. Daily indicator results are displayed on the unit, updated every shift and are reviewed with staff during the unit based huddle every 12 hours to provide a real time snapshot of unit performance. This helps staff recognize the impact that their work has on the unit goals.
Verification and validation of standardized work occurs daily on all SharedCare units. Verification is the process of ensuring staff perform work according to the standard and provides an opportunity for unit leadership, usually the charge nurse or manager, to coach staff to the standard when it is not being followed. Validation of standardized work occurs when the unit leadership performs the standard work his or herself to ensure accuracy and make adjustments as needed. Each LMS tool promotes effective communication and problem solving. This has created a safe environment for staff to be coached by making expectations clear and maintaining everyone’s focus on meeting these expectations. Through the use of LMS tools, staff are now acutely aware of what the nursing unit’s measures of success are and feel actively engaged in ensuring goals and targets are met not only monthly, but each and every shift.
Following the pilot, the SharedCare model has been implemented on 10 additional medical-surgical units. There have been overall improvements in the fall rate, HCAHPS scores, nurse turnover and staff engagement scores. The organization’s overall fall rate has plummeted from above 4.0 to less than 3.2. “Responsiveness of Staff” continues to improve and has averaged above 50 percent. Staff consistently rate their daily workload as “green,” or manageable, and are able to assist other team members, which has led to nurse turnover rates dropping from 25 percent to under 17 percent. Organizational employee engagement scores have also increased significantly.
SharedCare, designed and implemented by frontline staff using Lean healthcare methodology, has demonstrated sustained improvements at a time when many organizations are struggling financially or have been forced to lay off staff. The model’s roots in structured communication, standardized processes and the team nursing concept put the needs of the patient first in order to achieve patient specific outcomes.
Today’s post was written by Corey Yingling, MSN, RN-BC, lean coach at New Hanover Regional Medical Center.