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OA Main- Using Process Mapping to Optimize Care
Presented by [Phil Deering, Project Mgr. Stratis Health and Regional Coordinator for REACH]
(52-minute Webinar) [08-14-2013]
Karla Weng: Good afternoon everyone this is Karla Weng from Stratis Health and I’d like to welcome you all to today’s call on using process mapping to optimize care. This is the third of five learning sessions that are part of a statewide initiative to help improve and sustain quality of care provided by critical access hospitals.
Stratis Health with support from the Minnesota Department of Health offers a role in health and primary care is proud to host and offer this free programming for all 79 of Minnesota’s critical access hospitals.
Our presenter today is Phil Deering, a Project Manager here at Stratis Health and of the many roles he has here at Stratis he is the Regional Coordinator for the REACH program, the Regional HIT Extension Center for Minnesota and North Dakota.
We’re also grateful to have a guest speaker, Anita Zalinko, is with us today. Anita is an infection prevention practitioner, nurse and wears several other hats as does everyone at Chippewa County Montevideo Hospital. She’s been there since early 2012 working extensively on best practices and the prevention of catheter associated urinary tract infections or CAUTI. We’ll talk with Anita for a bit about that work and how it links together with process mapping.
With that I’ll turn the call over to Phil and Anita.
Phil Deering: Hi everyone. Thank you Karla. Good afternoon everybody. I’m sure I know a number of you on the line through my REACH work, so hello to all of those out there who have worked with me or any of our REACH colleagues.
Initially we were going to ask Anita to speak at the end of the presentation, however, one of Anita’s hats is also being a trainer and she has to get to the other side of the building by 1:00 to start a class, so we decided to start with our conversation with Anita. I’ll ask her some questions and Anita will tell you a little about her initiative.
Anita, we understand that you engage in an initiative designed to prevent hospital acquired infections, HAI’s and that you’re working specifically around CAUTI’s.
Could you tell us briefly about when you started the initiative and what the baseline was that you were working with and trying to change?
Anita Zalinko: We started the initiative’s actual paperwork and agreement in November of 2011. We put out press releases, but the data collection and the 2:40 in the National Healthcare Safety Network began in January of 2012. We didn’t really have a baseline because we had not done any CAUTI audits prior to that.
We started out Kay Peterson worked with us at that time through Stratis Health. We developed a work plan in April and revised it in May with much of it being based on a CAUTI readiness assessment that was sent out. All those things helped us look at what we were doing and what kind of improvements we could make. That’s how we got started.
Phil Deering: I understand from talking to Bruce here at Stratis as well that you didn’t really use… what you were trying to reduce or the metric you were using wasn’t CAUTI’s because you weren’t actually having any during the measurement period but you used a metric called ‘catheter days’.
Can you talk about that a little bit and why that was the appropriate thing to track?
Anita Zalinko: Since we didn’t have any CAUTI’s per the guidelines, the way to measure improvements is if you’re reducing the number of days that a person has a catheter in, so when we do our audits we actually do it by timing.
You put it in on November 18th at 11:00 o’clock and measure how many days from that time on. Then you want to improve and reduce the dates. If we look at a graph from January through March of 2012 we were up to 26.6% of catheter days and now we’re down to four. In fact, since January of this year we’ve been at 6, 6 and 4% so we feel pretty good that we’ve reduced the days.
The ways we reduced those days, everybody knows that the longer a catheter is in the more the chance it increases the risk of getting UTI’s associated with your catheter. Things we did to make changes were that we have nurse education days educating the nurses on getting an order to stop the catheter from the doctor, making sure we have good technique. We showed videos on how to put a catheter in appropriately because you get turnover of nurses and some people have bad habits.
We revised our computer assessment which was big, because in that assessment we included the days and times of insertion, the size and then also the removal. We did a lot of different things that were based on a readiness plan.
Phil Deering: Well first thing, congratulations. Karla’s eyebrows sprang up because we’re all excited because that’s a fabulous reduction. So basically, the method you used to decide what to do came from the work plan. Talk a little more about the method.
Anita Zalinko: There was a CAUTI readiness assessment that Kate had sent out to me back at the beginning of all this and that really made us look at what we were doing along with our processes, and how you can improve it. We developed a work plan from that part and we’re still improving.
We have found that even though we do our audits our people aren’t documenting all the time when they take it out and we still feel we can continue to reduce it, that people don’t need these catheters just for comfort as long as they need to and that’s been a big education for the nurses.
Bruce recently sent out this little card about removing urinary catheters and reasons that they’re indicated. He sent that out to us and then we modified it, reminding the nurses and then we applied one of those to every kit. I have an assistant and I, we taped one to every single catheter kit that’s in our supply room where the nurses are supposed to pull it off and put it on the chart to also remind the doctors.
So I think even though we’re doing well we can always do better.
Phil Deering: That’s the attitude behind quality, in that it’s not a single point but it’s a journey and to the extent that you realize that you can always continue to reduce that potential and you’ll have great outcomes.
In the presentation I’m about to give I’ll talk a lot about the underlying concept that if you want to change something you have to focus on who does what, and you’ve talked about that already that you looked at your current processes and changed them.
Did you use any sort of documentation at the beginning to clarify who was doing what?
Anita Zalinko: That was a hard thing for me to understand. Nurses do everything… the nurses need to do the documenting, to make sure things happen so I guess I didn’t quite understand that question. Who else would do it other than nurses?
Phil Deering: If you think about the whole process of the catheter insertion, there’s probably a part where the MD actually makes some decisions or does something, are there parts where nurses observe it.
Is the removal generally done by the nurse or the MD?
Is there inspection along the way where the MD assesses again?
Perhaps not, maybe it’s like catheter in, nurse times and removes.
Anita Zalinko: Yes. It’s pretty nurse driven as far as even getting the catheter in and out, because we’re one-on-one with the patients. We have a daily assessment where the nurse has to look and assess what’s going on with a catheter to see if everything’s right and if they need it. The doctors obviously have to write the order for insertion and removal, but it’s basically nurse driven.
A lot of catheters go in for surgery, so we had an issue in surgery where they weren’t putting the cath-secure on and it was coming to the floor and that was getting missed. The cath-secure comes as a kit, but they weren’t doing it because of the way they position the patient. We had to change that process and now they do and surgery now has to document that it’s in place, whereas they didn’t have to do that before.
Like I’m saying it’s nurse driven, managing the whole catheter thing. Doctors have a lot of other things they’re looking at with the patient and they forget about it. A lot of times the patients want the catheter to stay in, but we have to say hey if these patients never have a reason to get up we’ll never get them out of bed.
Phil Deering: That’s understood. So, clearly you did start to change some of the processes so you’re just saying for the cath-secure and making sure it went on, that took some process changes. Perhaps now there’s a work instruction about positioning the patient and secondly, making sure that when the kit is opened that it’s identified that the catheter goes in and the cath-secure goes on.
How do you document those processes or procedures?
Anita Zalinko: What do you mean?
Phil Deering: Is there a written instruction for these things or is it done verbally with training? How do you make sure everyone knows the new way of doing things?
Anita Zalinko: We do training because again we have nurse education days. We also have a nurse memo, a newsletter that goes out every week to all of nursing in both departments, surgery and on the floor. It advises of any changes that are happening. This is something new we’re doing and then we do individual feedback as well.
Since we’re auditing, and we’re a small hospital so we might only have 16 people that have had catheters this month, not a lot, but if we see that someone didn’t do something or didn’t document when we’re auditing, what I’ll do if the person is there that day I’ll go talk to them or email them and say this is what’s going on.
Basically, our computerized assessments has to be gone through everyday. It’s an ongoing assessment of the urinary catheter so everyday a nurse has to look to see if the cath-secure in place, is the foley draining, is it unclamped, and what does the urine look like? Our daily assessment should catch all that stuff. If someone missed it one day then the next shift should catch it.
Phil Deering: Did you have an assessment in place before that?
Anita Zalinko: We did but I greatly modified it once I got involved with doing the CAUTI. We were missing things. We modified the assessment and got it changed by our computer people. That holds people accountable, I mean they need to have why they put a foley in and then we constantly remind the nurses and check on them.
Phil Deering: That’s great. The last question I have you’ve already answered which was, are you continuing to tweak your processes now that you’ve implemented these changes? You made it very clear that you do that and there isn’t an end point where you’re going to stop doing that, something where we’ll be perfect and we won’t have to do that anymore.
Anita Zalinko: I don’t think that will happen.
Phil Deering: Right. I think too many humans are doing this work for us to get it to be perfect. That’s been very helpful to talk about. Some of these things we’ll go through in the presentation and others always make sense in any kind of forum on quality improvement and you’ve touched on so many important steps. Thinking about what you’re doing, having a plan to go ahead, changing important things, getting it in the computer system so it’s locked in and then continuing reinforcement through training and work direction and continuous improvement.
It’s all very impressive, thank you Anita.
Anita Zalinko: I just want to add that I find when you educate staff and they understand why we’re doing things that they are receptive and take ownership of it. They feel good when they’re doing things the right way and it’s for a good reason.
Phil Deering: Thank you for that, very well stated.
Anita Zalinko: Thank you.
Phil Deering: For everyone on the line now, I’m going into the presentation and I’ll try to remember to tell you when I’m changing pages. We won’t spend time on the first one. This is a joke I included that says… brevity is the soul of wit, if you don’t understand the joke now or at least maybe if your family is like my family, this isn’t so much of a joke and more like how your spouse feels about your ability to fix things.
The next slide is animated and doing the hokey-pokey. The point is that when we get to the end, again we’ve seen a flow chart in action. A flow chart takes steps and makes them clear to us, breaks them down, but we come up with the question is that what it’s all about? We know it’s not really all about the hokey-pokey.
Following that are some of the things that it really is all about and we know that so many process improvement efforts and maybe even deeper, so many things that we do in our rapidly changing environment have the potential to cause a lot of problems. One of the things we’ve seen with critical access hospitals very much is that when the implementation of the EHR goes on, it’s not always done completely and the new processes aren’t always in place.
Let me give you a couple of examples from real life that we’ve seen. One is where the hospital installed computers in every room or at least are on stands so that the computer is in the room with the patient.
We know the MD’s in many places are still not entering their orders, so the nurses then instead of taking advantage of the expense of having the computer in there or the doctors are taking the orders and going back to the nursing station because that’s where they always used to sit to enter the orders. Of course, there are many things that are going wrong there, inefficiency being one and second, because the orders aren’t being entered right on time and not entered by the MD, which is very much the best practice, we’re not taking advantage of the power of the EHR.