nurturing is at the heart of healing “it would be better if everyone would work together as a...
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Nurturing is at the heart of healing
“It would be better if everyone would work together as a system, with the aim for everybody to win.”
W. Edwards Deming
Mary Hickey, MBA, Six Sigma Master Black Belt
Mary Hickey, AMNCH
Forces Impacting Patient and Family Centered Care
“Push” Forces: challenging the Status Quo
Health care reform Patient Safety Consumer Movement / Patient
rights Transparency demands Croke Park Agreement / Cost
effectiveness Licensing
“Pull” Forces: Making the Future Attractive
Organising the healthcare system around the patient and family works for everyone
Optimizing the patient experience correlates with other outcomes, including clinical, financial and staff satisfaction
Patient activation and self management is enhanced, achieving better chronic disease outcomes
Caregivers are seeking a better patient experience for those they serve and for their own families
Mary Hickey, AMNCH
DOHC Reports on Lifestyle Habits of the Irish Population
Mary Hickey, AMNCH
Social cultural milieu of Ireland is changing….
Increasing numbers of different ethnic groups from around the world are migrating to Ireland
According to 2006 census figures, 10.2% of people living in Ireland belong to minority ethnic groups
Highest number from EU – 40% Polish, others mainly from Asian countries China, India, Pakistan and Africa countries mainly Nigeria
Diets differ significantly to the diet of the Native Irish population in that it may contain a large amount of carbohydrate foods, pulses, legumes, vegetables and fruit. Higher intake of complex carbohydrates and lower fat intake
Diet greatly influenced by culture, religion and beliefs Another study was published by HSE West on behalf of The Community
Nutrition and Dietetic Services, Jan 2010 entitled “Minority Ethnic Groups: A Nutrition Resource for Dieticians and Health professionals”.
Mary Hickey, AMNCH
HSE Quality Programme
Mary Hickey, AMNCH
Governance framework for Patient Safety and Quality
Knowledgeable patients receiving safe and effective care
from skilled professionals in appropriate environments
with assessed outcomes.
Report of the Commission on Patient Safety & Quality Assurance
DOHC, 2008
Mary Hickey, AMNCH
Food and Nutritional Care in Hospitals – Guidelines for Preventing Under – Nutrition in Acute Hospitals“Caterers play an important role in
helping patients to make healthy and nourishing food choices. Together with hospital dieticians, they can create a supportive environment for healthy nutrition. All food staff, by ensuring that patients eat well, help to improve both their physical and mental health, and thus speed up their recovery from illness.”
Mary Harney, TD
(former Minister for health & Children).
Published by DOHC in 2008
Mary Hickey, AMNCH
Promoting good nutritional care in hospitals The length of time a patient spends in hospital and the cost of that stay is linked
to the patient’s nutritional status. Under nutrition in sick patients is associated with :
Impairment of every system in the body: muscle weakness, particularly in respiratory muscles, reduction of the ability of the immune system to function; and alterations in the structure and function of the gut
Delayed wound healing Apathy and depression Reduction of appetite and ability to eat High rates of mortality
These change combine to increase both the length of time a patients spends in hospital and the cost of the stay. Apart from this the patients quality of life is severely affected, both while in hospital and after discharge.
A review of 22 surveys in 70 US hospitals showed that patients receiving early nutrition intervention had a shorter length of stay (average 2.1days) a direct saving of $697 per patient per day. Kings Fund UK, calculated the savings from treatment of under – nutrition would be in the region of 453m each year.
Mary Hickey, AMNCH
Adult Inpatient Admissions [Excluding Psych] by Adm Type
0
200
400
600
800
1000
1200
Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09
No. o
f Adm
issio
ns
A/E Elective Other
Mary Hickey, AMNCH
% Adult Bed Occupancy [Exclude Psych, ITU, CCU & Emergency Bed Ward]
60%
70%
80%
90%
100%
110%
120%
130%
Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09
Surgical Medical Total
Mary Hickey, AMNCH
Nutritional Status of Hospitalised Patients can be compromised by a number of factors…
1. Failure to detect poor nutrition
2. Poor recording of information about patients’ nutritional status (such as weight loss)
3. Poor referral systems
4. Fragmented working practices
5. Inadequate educational or training programmes
6. Inadequate ward staffing
7. Confusion over who has the primary responsibility for patients’ nutrition
(Ref: Jan Savage, 2005, “Patients’ nutritional care in hospital: An ethnographic study of nurses’ role and patient s’ experience” RCN Institute London)
Mary Hickey, AMNCH
Nurses’ involvement in nutritional care has varied
over time…… By mid 20th century, matrons and senior nurses had relinquished direct managerial control over catering and other housekeeping functions in hospitals
Retained influence over standards of service provision (in the UK specifically after widespread “contracting out”)
Some blurring of roles and responsibilities of nurses and non – nurses in the preparation and serving of food
Initial nutritional assessment, care plan and monitoring (recording of food and fluid intake and weight)
Implementing the advice of dieticians and Speech & Language therapists Checking patient menu card choices Helping to feed patients who need help and providing appropriate
implements for others
Mary Hickey, AMNCH
Mary Hickey, AMNCH
“If you always do what you’ve always done
You’ll always get what you’ve always got"
Mary Hickey, AMNCH
“Eighty-five percent of the reasons
for failure to meet customer
expectations are related to
deficiencies in systems and
process… rather than the employee.
The role of management is to
change the process rather than
badgering individuals to do better.”
W. Edward Deming on Processes
“Will be cross-functional, process-driven”
Mary Hickey, AMNCH
There is no secret formula to providing good food.
“It’s a matter of care and attention, and making sure patients get what they like”.
Lord Grossman
Mary Hickey, AMNCH
NHS - Better Food Campaign
Launched in May 2001 Some of the dishes were developed by
a team of volunteer “leading chefs” including Anton Edelmann of the Savoy
Worked with NHS caterers to improve taste and Nutritional quality
At least 3 “chef’s recipes” must now appear each day on NHS menus in Acute Hospitals
Cost the government £40million over 4 years
Aim was to raise the food standard in all hospitals to the level of those of the best
“The challenge is to embed the principle that good food is critical for the patients’ physical and psychological recovery. Even how food looks, the colour and smell can buck you up.” Lord Grossman
Mary Hickey, AMNCH
Stanford University Hospital…..Stanford is often referred to as “the Farm” in keeping with its
history and location on land donated by its founders, Jane and Leland Stanford. The more than 8,000-acre Palo Alto Stock Farm was given in the grant establishing the University, which opened in 1891.
The food we serve is part of the commitment the hospital makes to help our patients heal as quickly as possible and to feel comfortable and cared for while they are in hospital.
The hospital invited Chef Jess Cool, a nationally recognised chef, restaurateur and food writer to develop recipes with the hospitals catering staff.
Mary Hickey, AMNCH
Other hospital initiatives
Kaiser Permanente, Northern California started hosting in hospital farmers markets back in 2003 and in 2006 began partnering with small local farmers to provide patients with organic fruit and vegetables
Healthcare without Harm, launched a programme in September 2009 to reduce meat offerings in patient meals and staff cafeterias by 20% in 12 months. The average portion of meat in the US is 8ozs while the recommended portion is 5/6ozs – over consumption of meat contributes to the overwhelming cost of US health system est. to be $147B as a result of obesity alone as well as climate change, water, air pollution. The food system accounts for 10% of overall energy use in the US.
“Balanced menus is a climate change reduction strategy that also protects the effectiveness of antibiotics and promotes good nutrition.”
Healthcare without Harm
Mary Hickey, AMNCH
“All improvement takes place project by project, and in no other way.”
Dr. Joseph M. Juran
DMAIC - A Project Management Method
Mary Hickey, AMNCH
Define
Measure
Improve
Analyse
Control
Define the problem and project
Measure & gather current baseline data
Analyse the data, identify root cause(s)
Improve by addressing root cause(s)
Control to sustain gains
The DMAIC (D-MAY-IK) Model
Don’t jump to conclusions – arrive at the solution !
Lean Six Sigma Key ConceptApply Rigour &
Discipline
Mary Hickey, AMNCH
Central theme is the elimination of waste. Waste is any activity that does not add value for the customer.
The approach is typified by the Toyota Production System.
Key measurement for Lean is value adding time.
Central theme is to create processes and products which are virtually defect and variation free.
The approach is typified by Motorola and GE
Key measurement for Six-Sigma is variation.
lowercosts
fasterprojects
higherquality
Lean Six Sigma
LeanSigma
SIZE
Mary Hickey, AMNCH
Knowledge is in the Data
““When you can measure what you
are speaking about, and express it in
numbers, you know something about
it; but when you cannot express it in
numbers, your knowledge is of a
meager and unsatisfactory kind.”
Lord Kelvin, a Scottish
mathematician and physicist who
contributed to many branches of physics
1824 – 1907
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Extent of Knowledge(Derived from observation and measurement)Extent of Knowledge(Derived from observation and measurement)
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Extent of Knowledge(Derived from observation and measurement)Extent of Knowledge(Derived from observation and measurement)
1. We use previous experience
2. We collect data and then look at the numbers
3. We group data so as to form charts and graphs
4. We use census data with descriptive statistics
5. We use sample data with descriptive statistics
6. We use sample data with inferential statistics
As the level of analysis increases
so does our success
Mary Hickey, AMNCH
The Productive Ward: Releasing time to care The Productive Series is a set of programmes
developed by the NHS Institute of Innovation and Improvement to help NHS teams redesign and streamline the way that they work.
The three main components are:
Knowing how we are doing (recording, displaying and using key measures) The well organised Ward – workplace organisation Patient status at a glance – improving the patients status using display boards
Videoing of Mealtimes is a core component of this programme to identify areas for improvement
Mary Hickey, AMNCH
Productive Ward cont.
“The major key to the success of the Productive Series is the empowerment of staff to enable them to drive forward improvements, overcome difficult practice challenges and make positive changes to the way they work. The process encourages a continuous improvement culture to ensure that results are solid and lasting”.
Airedale NHS Foundation Trust
“Completing the module has enabled the staff to spend more time with patients monitoring their dietary intake at meal times, this is in addition to the good work we have already achieved with the Royal College of Nursing on the Nutrition Now campaign”.
County Durham and Darlington NHS
Savings of £100,000 per year have been made by Hull and East Yorkshire Hospitals NHS Trust by working on the ‘Productive Mealtime’ module within the Productive Ward programme
Mary Hickey, AMNCH
Why Lean Healthcare?
20,000 incorrect drug prescriptions per year U.S. 500 incorrect surgical operations per week 50 new born babies dropped at birth per day Enormous defect rate (estimated at nearly 45% by the
New England Journal of Medicine, June 26, 2003) Cost escalation (e.g., General Motor Corporation
reported in 2005 that healthcare expenditures equate to $1,525 per car)
“For every dollar spent on healthcare over 75% is spent on non-patient care activities of communicating, scheduling, coordinating, supervising, and documenting care.” HealthMEDX, 2005
Mary Hickey, AMNCH
How do you do it?
1. Stabilize processes
2. Standardize processes
3. Simplify processes
Mary Hickey, AMNCH
Process levels
Greet patient
Identify Patient
LogPatient
Queuepatient
Take patient details
Confirm patient’s
GP
Confirm Condition /
injury
Advise patient of
next steps
Level 1
Level 2BusinessProcesses Map / SIPOC
Core Business
Level 3
Detailed Sub-process Map
Patient Admission
Focuses on the REAL root cause(s) of problems
Mary Hickey, AMNCH
Current State
Future State
Mary Hickey, AMNCH
Stabilize – Understanding WasteWaste: anything that adds cost or time without
adding value
Mary Hickey, AMNCH
Understanding Waste
Unnecessary Services or Overproduction – producing work prior to it being required is waste and is the greatest of all the wastes
Unnecessary Motion - any movement of people, paper, and/or electronic exchanges that does not add value is waste
Excess Transport – the extra or unneeded time element associated with the delivery of work or a patient to a process
Over-processing - putting more work or effort into the work required by
internal or external customers is waste
Mary Hickey, AMNCH
Understanding Waste cont.
Inventory (Time) - work piles, excessive supplies, and excessive signature requirements are waste
Defects or Mistakes - refers to all processing required creating a defect or mistake and the additional work required to correct it
Underutilization of People - is a result of not placing people where they can (and will) use their knowledge, skills, and abilities to the fullest (considered an 8th Waste)
Mary Hickey, AMNCH
Suggestions for Improvement
A Nutritional Committee in place in all hospitals to include caterers, dieticians, speech & language, food service staff, nurses and a clinician to help develop closer collaboration
Develop a hospital policy on nutrition Protected mealtimes and hospital policy on managing conflicting priorities Nutritional screening tool (MUST) to be used in the initial assessment of patients to
identify those at risk and thereafter becomes part of nursing notes Regular Patient Satisfaction Surveys – results published A system to manage complaints about food and there resolution A streamlined system for special diets with a description of the diet on the menu card Nutritional training for medical and nursing staff as part of their formal education and a
refresher course for all staff involved in the preparation and service of food – should also be a standard element of induction
Tray waste audits – develop and validate a system for food recording Develop patient information leaflets which could be provided to patients in their pre –
admission pack for elective patients Introduce Food Moulds for specific diets
Mary Hickey, AMNCH