Sunday, January 27, 2013

5 minute Process Improvement huddles on our urology ward


Here’s a fresh process improvement (PI) project.  And a hidden agenda or two.

Last week, a staff member on our urology ward approached me with a concern about how we were managing voiding trials for men after prostate surgery.  TURP (transurethral prostatectomy) is a commonly-performed operation for men who are having difficulty passing urine because their prostate gland is enlarged.  After the surgery, men stay overnight in the hospital with a catheter (rubber drainage tube) in their bladder.  Most men have the catheter removed the next morning.  After the catheter is removed, we want to be sure that the man can pass his urine – a “voiding trial”.  After a successful voiding trail, the man can go home later that day.

Because the bladder is kept empty by the catheter, it may take several hours for it to fill enough for the man to pass urine.  Also, some men may have difficulty urinating initially and it may take several attempts before we’re confident that they are voiding well.

The problem:  It’s unpredictable how long a voiding trial will last.  It may take several hours.  This means that it’s difficult to be sure what time the man should arrange to be picked up at the hospital - a significant issue in Saskatchewan when family members may be traveling several hours to reach Saskatoon.  Also, it’s difficult to know when the man’s hospital room will be vacated and be ready for use by another postoperative patient. 

As the staff member informed me, in order to expedite room turnover, some postop men had been asked to wait in our ward’s common room while conducting their voiding trial.  This meant that they would use a public washroom to void and then bring the urinal to the nurse for measurement.  If there was any question about how well they were emptying their bladder, the nurse may perform a bladder ultrasound scan.  If the bladder isn’t emptying well, the nurse may reinsert a catheter to drain the residual urine.  All these steps can be performed comfortably and privately when men are in their own hospital room.  (Our ward is extremely fortunate to be able to provide private rooms for all patients.) The process may not be so comfortable and private when men are waiting in the common room.  This was the staff member’s concern.

I agreed with that concern, and at the same time I appreciate the pressure that managers feel to serve the next patient who needs to be admitted to an open bed later in the day.  We want to make sure that patients being admitted through the operating room or emergency department can have a bed promptly, both for their own comfort and also to reduce congestion in other areas of the hospital.  We agreed that we weren’t satisfied with the solution being tried currently, but there was still a problem to be addressed. We need a new process.

Hidden agenda: Process improvement can move at a glacial pace.  Sometimes the formal structure around quality improvement (project charters, team assignments) can be so daunting that people are too intimidated to try to make a change.  I accept that large-scale projects are more successful with a formal structure, but smaller process improvements may never see the light of day.  This has been a concern for me as I watch our health region’s managers and leaders participate in Lean training.  Rapid Process Improvement Workshops (RPIWs) take up 100% of the team’s time for the week of the workshop.  In addition, the team leaders spend significant time in preparation before the RPIW week.  I like structure and discipline in my work (just ask anyone who has to work with me in the OR…), but I wonder if this degree of investment pays off adequate returns in process improvement.  Time will tell.

While time is telling, however, we need to continue improving our services at the microsystem level.  If our ward, or particular clinical problem, isn’t chosen for one of the initial RPIWs, we still need to make changes.  So, I want to explore a less formal approach to PI.

Every weekday morning, our urologists make rounds to visit inpatients on our ward.  Immediately following that, the urologists and nurses meet to discuss patient management plans.  (No, we haven’t quite graduated to multidisciplinary bedside rounds.  Yet.)  The urologists need to get to the office or the OR, and the nurses are ready to go off shift, so we don’t have time to have a formal (read: lengthy) PI meeting.  On Tuesday, I asked for 5 minutes at the end of rounds to present the problem (see above).  There was agreement that we could improve this process.  The initial idea was that urologists should “pre-program” catheter removal by leaving orders the night before about what conditions needed to be met in order for the nurse to remove the catheter the next morning.  We’re interested in things such as whether or not a man has a fever (an objective measure) and how much blood is mixed with his urine (a more subjective measure).  If the criteria are satisfied, the nurse will remove the man’s catheter early in the morning (perhaps 0500) to start the voiding trial.   The downside of this plan is that the man would be wakened early in the morning, and it would also require introducing a new process, i.e. delegating the decision for catheter removal from urologist to nurse.

That was pretty good work for a 5 minute session.  And a classic case of jumping to solutions without first looking at the system!

On Thursday morning, we reconsidered the PI in light of new information from nursing staff.  While physicians may be writing the order by 0730, catheters may not actually be removed until 0900 or 1000.  This is because nursing shift change happens around 0730 and the day shift start their work with administering medications and helping patients prepare for breakfast.  It’s a very busy time for them.  However, if catheters were consistently removed by 0800, perhaps it wouldn’t be necessary to develop a new process to remove them at 0500.

That was our 5 minutes for PI on Thursday.  We decided the next step would be for the ward’s quality improvement nurse to collect data as to when catheters were actually being removed.  TURP is a common enough operation that we may have 3 or 4 men on the ward over the next 3 days.  I’d like to see this data on a simple chart that we’ll post in our meeting room. 


After rounds finished on Thursday, another nurse approached me with some research she had been doing.  A colleague of hers worked with urologists in another part of the hospital and mentioned that one member of our group sometimes expedites voiding trials by instilling saline into the man’s bladder via the catheter just before removing it.  This cuts down on the time needed to fill his bladder the “natural” way.  This would be simple to do on the urology ward.  I’ll bring this idea forward in our next PI huddle this week.

Hidden agenda: On Friday of last week, we received a memo from our health region administration that, due to GI virus-related ward closures, our hospital is running “over-capacity”.  This means, among other things, that surgeries may be cancelled.  We’ve been encouraged to discharge patients promptly (yet, of course, appropriately).  If we can demonstrate rapid changes to our care processes without the need for a formal RPIW, perhaps this PI model can help other wards deal with their patient flow issues.

I’ll keep you posted.

42 comments:

  1. Hi Kishore
    This is so exciting! Real live point-of-care experts thoughtfully examining the care they provide, testing out theories and potential solutions. You have no idea how excited your story has me.

    Its not exactly clear to me yet when you choose an RPIW over just trying something new using our QI/PI tools (I've only completed the classroom parts of Saskatchewan's Lean Leader Certification and am far from having any expertise in matters such as these). But it seems to me that the freedom of NOT being in the structure and discipline of an RPIW can be a gift. Within minutes, as you demonstrate, a small group of interested people can question and challenge the status quo. What I do know is that the vast majority of change and improvement that we will do as a system will be from groups such as yourself continuously experimenting with small tests of change. RPIWs have their place for sure especially as you work across care groups or challenge "policy," but it is the quest for continuous daily improvement that will get us (and our patients) where we need to go.

    Speaking of patients.... Have you asked a few of your TURP patients what problems they have identified and what solutions they have thought about as they recuperate in hospital?

    Keep up the great work and I look forward to learning what your team does next

    susan

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  2. What an awesome post! I would quibble a bit with the idea that what you are doing is unstructured. It's clear to me that at least one of you has enough depth of knowledge that you are still facilitating the team to work within structures like PDSA , whether documented or not. As well, I believe team huddles are a key improvement structure that are often underused. What is so wonderful about what you are describing is that it is sounding like improvement work is becoming integrated into your regular work instead of being seen as a separate activity or project...careful now, you are getting dangerously close to the realizing the ideal of every one having two jobs - do the work and improve the work :-)

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