Accelerating the Pace of Clinical Transformation Through a ‘Continuous Improvement’ initiative

Over the past eight months, nurses at Cleveland Clinic’s Zielony Nursing Institute and Hillcrest Hospital have been looking to accelerate the pace of clinical transformation by instituting a Continuous Improvement (CI) initiative designed to engage all caregivers in better delivering safe, compassionate, affordable care to our patients by standardizing operating procedures and eliminating waste.

CI is nothing new to healthcare or to nursing. It is a philosophy that has been used for decades in various industries, and in the healthcare space it came to fruition in 2001 with the release of the Institute of Medicine (IOM) report, Crossing the Quality Chasm: A New System for the 21st Century. This report was a call for health organizations to renew their focus on improving the quality and safety of patient care in all delivery settings.

As provided by the National Learning Consortium (NLC) in a 2013 report, the key to CI initiatives is using a structured planning approach to evaluate current practice and improve systems and processes to achieve desired outcomes and future vision. This commonly includes strategies that enable team members to assess and improve healthcare delivery and services.

A culture of improvement

CI begins with a culture of improvement for the patient, the practice and the general population. The CI initiative at Hillcrest Hospital was implemented as a pilot program within the hospital’s 5-Main medical-surgical nursing unit. Throughout the Cleveland Clinic health system, this nursing unit has been one that often scores fair in patient quality and experience, but has consistently shown room for improvement in these areas.

Through much planning and discussion, the Cleveland Clinic Executive Nursing Leadership team felt the Hillcrest 5-Main unit would be an ideal pilot and, pending results, could pave the way for an enhanced systemwide CI initiative with the potential to improve patient care and employee engagement, reduce unit-based costs and increase care affordability.

An initiative built on Caregivers

The hallmark of CI is that every caregiver is capable, empowered and expected to make daily improvements in quality, safety, patient experience, engagement and care affordability.

Led by a dedicated team of nursing professionals, including members of Cleveland Clinic’s CI department as well as the unit-based nurse manager, CI project manager and three frontline caregivers – 5-Main began the initiative in June 2014 with the support of a multidisciplinary steering team and the unit shared governance team.

Caregivers were first introduced to continuous improvement principles that guide implementation of these techniques. These techniques allow caregivers to increase the value they provide through relentless improvement and elimination of waste.

Most familiar to the 5-Main nursing unit from previously instituted CI projects was the concept of ‘5S,’ which as outlined by the U.S. Environmental Protection Agency, uses five Japanese words to describe an efficient workplace organization method that optimizes productivity and maintains order to achieve more consistent operational results.

Caregivers were also taught additional core practices of problem-solving, visual management, standardization and value stream thinking. They were introduced to a video on eight wastes, which highlights waste examples that get in the way of delivering safe, compassionate care to our patients such as transportation, inventory, motion, waiting, over-production, over-processing, defects (poor quality), and underutilization of human talent. The content prepared caregivers to look at different wastes that may get in the way of providing highly satisfying, value-based patient care.

To initiate a plan of action, caregivers were tasked with answering the following questions:

• What makes a good day for us?
• What gets in the way of us having a good day?

The result? Forty proposed unit improvement ideas.

Taking action: “Improvatorium” leads to new SOPs

To effectively share, discuss and track the new ideas, Hillcrest caregivers placed them on a Kaizen board that they displayed in a unit break room they dubbed the “Improvatorium.”

While Hillcrest Hospital has instituted CI initiatives in the past, the difference with this one is that it explicitly aligns with organizational goals, is a strategic process developed by caregivers, and supports doing what is right in a manner that can be sustained through standardization and consistency.

From the “Improvatorium” ideas, the 5-Main nursing team identified one focused CI project designed to improve patient responsiveness. The team’s work led to the development of new standard operating procedures (SOPs) for three key areas and included the following:

1. Admission Process: Now offers a caregiver alert for any newly admitted patient en route to the unit. Provides the patient with a welcome letter as well as nurse manager rounding and ensures the patient room is properly set up upon arrival, they are introduced to their caregivers, and that an admission checklist is completed shortly after arrival.
2. Call Light Process: Now includes call light mapping and quicker escalation times to streamline and expedite calls directly to the caregiver. Also includes caregivers entering their own assignments into the voice communication system, Vocera, and standardization of the nurse float process to ensure awareness of and standardized response to the call light process.
3. Staff Assignment: Now provides an explicit and standardized process for initial staff assignment that integrates the roles of technology related to caregiver assignments or any adjustment of assignment to minimize delays or late patient care changes.

Results showcase improved HCAHPS scores

At Hillcrest Hospital, creating this culture of improvement has made all the difference in ensuring high-quality patient care – successfully resulting in improved patient experience scores.

In January 2015, every 5-Main caregiver received thorough education of the new CI initiative and the resulting SOPs, and by February, all three SOPs were implemented. To date, the 5-Main Hillcrest Hospital nursing unit successfully achieved 96th percentile (88.1 percent top box score) in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patients’ perspectives in care survey’s “Nursing Communication” domain score and 83rd percentile (75 percent top box score) in the survey’s “Responsiveness“ domain.

As a result of 5-Main’s success, a broader rollout is being considered for later this year.