Using Gemba Boards to Facilitate Evidence-Based Practice in Critical Care

Reducing costs and improving patient recovery through a nurse-driven centralized spinal orthoses program on a post-surgical unit: A quality improvement initiative

Background

An external vendor providing off-the-shelf spinal orthoses to inpatients created significant costs and barriers to quality care for spinal surgery patients. A nursing leadership team initiated a quality improvement project to reduce the cost of providing off-the-shelf spinal orthoses and improve the care provided to spinal patients.

Objective

To develop and evaluate a nursing-led process for providing off-the-shelf orthoses to spinal surgery patients and eliminate high costs.

Design

Quality improvement project evaluated as a retrospective interrupted time-series.

Setting

Post Surgery Inpatient Unit Level II Trauma Center in a United States hospital located in Florida.

Participants

Vendor Program: 134 patients; Centralized Program: 155 patients.

Methods

The nursing leadership team developed a centralized spinal orthoses program where the bedside nurse fitted the patient with a spinal orthosis, eliminating the need for an external orthotist. The study quantifies changes in study metrics by comparing patients identified through chart review who received care in the vendor program to those who received care in the centralized program utilizing nonparametric statistical techniques.

Results

The centralized nursing-led spinal orthosis program allowed the unit to mobilize patients more quickly than patients managed under the vendor program (3.85 hr. [95 % CI: 1.27 to 7.26 hrs] reduction; p = 0.004). The overall length of stay was reduced by 0.78 days ([1.34 - 0.02 days]; p = 0.063) or 18.72 h. While the statistical test did not indicate significance, the 18.72-hour reduction in length of stay represents a potential clinically relevant finding. Evaluating patients that suffered a primary spinal injury and no complications (vendor program: 54 patients; centralized program: 86 patients) showed a similar reduction in time to mobilization (4.5 hr reduction [0.53 to 12.93 hrs]; p = 0.025), but the length of stay reduction increased to 1.02 days [0.12 to 1.97 days], a difference determined to be statistically significant (p = 0.014). Centralizing the process for providing off-the-shelf spinal orthoses reduced the cost of a thoracic-lumbar sacral orthosis by $1,483 and the price of a lumbar-sacral orthosis by $1,327. Throughout the study, the new program reduced the cost of providing spinal orthoses by $175,319.

Conclusions

The results demonstrate that the nursing-led centralized spinal orthosis program positively impacted the quality of care provided to our patients while also reducing the cost of delivering the orthoses.

Tweetable abstract

A nursing-led centralized spinal orthosis program reduces the cost of care while reducing time to mobilization and length of stay.

Kintsugi: Fosters Student Nurse Externs' and New Nurse Residents' Sense of Respect, Resilience, and Rebuilding Post Pandemic

Kintsugi serves as a powerful metaphor for nurse externs and residents to identify lessons learned from the pandemic and to refocus on the golden cracks to foster respect, resilience, and rebuilding. Kintsugi encourages nurses to embrace their challenges, find strength in their vulnerabilities, and grow from their experiences.

Changes in evidence-based practice self-efficacy among nursing students and the impact of clinical competencies: Longitudinal descriptive study

INTRODUCTION

Evidence-based practice (EBP) is essential to ensure patient safety and improve the quality of nursing care. Nursing students' self-efficacy in employing EBP is crucial for the formation of a culture of EBP in healthcare organizations.

OBJECTIVE

This study aimed to investigate the changes in nursing students' self-efficacy in employing EBP and the extent to which clinical performance affects these changes.

METHODS

This study was a longitudinal descriptive study. Participants were nursing students who had received education on EBP theory and had clinical practice experience. Convenience sampling was used to select nursing students in their third year of study at a nursing college located in the southern region of Korea in 2020. The researcher measured EBP self-efficacy and clinical competence using an online survey tool at three time points (second semester of third year, first semester of fourth year, and second semester of fourth year). Multilevel modeling was used to identify factors affecting changes in EBP self-efficacy.

RESULTS

The results showed that nursing students' EBP self-efficacy increased over time. Nursing leadership (p = .022), nursing skills (p = .028), communication (p < .001), and nursing process (p = .003) were significant factors that affected the changes in EBP self-efficacy. Individual differences in initial levels and change rates were still observed.

CONCLUSION

Systematic education on EBP theory and practical training should be provided to nursing students from the beginning of their studies to graduation to deepen their EBP and clinical competence.

Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

Current State of Critical Care Nursing Worldwide: Current Training, Roles, Barriers, and Facilitators

This review provides insights on the current state of roles and responsibilities, on-the-job training, barriers, and facilitators of critical care nursing (CCN) practice. Some of the established roles and training of CCN were providing care for acutely ill patients, delivering expert and specialist care, working as a part of a multidisciplinary team, monitoring, and initiating timely treatment, and providing psychosocial support and advanced system treatment, especially in high-income countries. In low-resource settings, critical care nurses work as health care assistants, technical or ancillary staff, and clinical educators; manage medications; care for mechanically ventilated patients; and provide care to deteriorating patients.

Reducing Changeover Time Between Surgeries Through Lean Thinking: An Action Research Project

Background

Maximizing the utilization of the operating room suite by safely and efficiently changing over patients is an opportunity to deliver more value to patients and be more efficient in the operating suite. Lean Thinking is a concept that focuses on the waste inadvertently generated during organization and development of an activity, which should maximize customer value while minimizing waste. It has been widely applied to increase process efficiency and foster continuous improvement in healthcare and in the operating room environment. The objective of this paper is to provide insight on how healthcare professionals can be engaged in continuous improvement by embracing Lean Thinking and ultimately reducing changeover time between surgeries.

Methods

Using an action research approach, Lean methodology such as Gemba walks, Process Mapping, Root-Cause-Analysis, and the Single Minute Exchange of Dies (SMED) system was applied to understand the causes of variability and wastes concerning changeovers and improve processes in the context of gynecological- and general surgery. Data were collected and analyzed through observations and video recordings. Problem and issue have been raised to management team attention and included in the annual balanced scorecard of the hospital. This initiative has been also made relevant to the team working in the operating suite and related processes before and after the entry of the patient in the operating suite.

Results

Improved patient flow and inter-professional collaboration through standardized and safer work enabled effective parallel processing and allowed the hospital to reduce changeover time between operations by 25% on average, without changes in terms of infrastructure, technology or resources.

Conclusion

Lean thinking allowed the team to re-evaluate how the whole operating suite performs as a system, by starting from a sub-process as changeover. It is fundamental in order to improve further and obtain sustainable results over time, to act on a system level by defining a common goal between all stakeholders supported by a management and leading system such as visual/weekly management, optimizing planning, implementing standard-works to be followed by every associate and guaranteeing the role of the surgeon as process driver who pull performances.

ECMO During a Pandemic: A COVID-19 Quality Improvement Process

Extracorporeal membrane oxygenation is a modified form of cardiopulmonary bypass and a complex adult critical care therapy. No evidence appears to exist on sustaining relevant quality nursing standards during a pandemic. The aim for this quality improvement process was to address nursing provision in real time related to extracorporeal membrane oxygenation in a pandemic, providing fundamentals for future readiness. The Ishikawa fishbone diagram and a Plan-Do-Study-Act cycle were methods used. Process changes included implementation of a communication algorithm, an alternative nursing care model, increased nursing staffing and leadership visibility, use of perfusion services for nursing task support, and minimized nursing documentation. Changes applied were successful. We recommend increasing nursing staffing volume and support resources, applying a communication algorithm, and minimizing documentation requirements. These strategies are generalizable to other clinical nursing areas in similar pandemics or disasters.

Huddles and their effectiveness at the frontlines of clinical care: a scoping review

BACKGROUND

Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research.

METHODS

A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts.

RESULTS

Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%).

DISCUSSION

Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).

Interprofessional, multitiered daily rounding management in a high-acuity hospital

PURPOSE

The purpose of this explanatory case study is to explain the implementation of interprofessional, multitiered lean daily management (LDM) and to quantitatively report its impact on hospital safety.

DESIGN/METHODOLOGY/APPROACH

This case study explained the framework for LDM implementation and changes in quality metrics associated with the interprofessional, multitiered LDM, implemented at Saint Francis Hospital and Medical Center (SFHMC) at the end of 2018. Concepts from lean, Total Quality Management (TQM) and high reliability science were applied to develop the four tiers and gemba rounding components of LDM. A two-tailed t-test analysis was utilized to determine statistical significance for serious safety events (SSEs) comparing the intervention period (January 2019-December 2019) to the baseline period (calendar years 2017 and 2018). Other quality and efficiency metrics were also tracked.

FINDINGS

LDM was associated with decreased SSEs in 2019 compared to 2017 and 2018 (p ≤ 0.01). There were no reportable central line-associated blood stream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) for first full calendar quarter in the hospital's history. Hospital-acquired pressure injuries were at 0.2 per 1,000 patient days, meeting the annual target of <0.5 per 1,000 patient days. Outcomes for falls with injury, hand hygiene and patient experience also trended toward target. These improvements occurred while also observing a lower observed to expected length of stay (O/E LOS), which is the organizational marker for hospital's efficiency.

RESEARCH LIMITATIONS/IMPLICATIONS

LDM may contribute greatly to improve safety outcomes. This observational study was performed in an urban, high-acuity, low cost hospital which may not be representative of other hospitals. Further study is warranted to determine whether this model can be applied more broadly to other settings.

PRACTICAL IMPLICATIONS

LDM can be implemented quickly to achieve an improvement in hospital safety and other health-care quality outcomes. This required a redistribution of time for hospital staff but did not require any significant capital or other investment.

SOCIAL IMPLICATIONS

As hospital systems move from a volume-based to value-based health-care delivery model, dynamic interventions using LDM can play a pivotal role in helping all patients, particularly in underserved settings where lower cost care is required for sustainability, given limited available resources.

ORIGINALITY/VALUE

While many hospital systems promote organizational rounding as a routine quality improvement process, this study shows that a dynamic, intense LDM model can dramatically improve safety within months. This was done in a challenging urban environment for a high-acuity population with limited resources.

Assessing the Impact of an Original Soft Communicative Robot in a Nursing Home in Japan: Will Softness or Conversations Bring more Smiles to Older People?

It has been reported that robotics-aided care can contribute to enhancing older people's social participation and quality of life in nursing homes, while simultaneously reducing the burden on care professionals at nighttime. Due to increasing demand for social care and the relative workforce shortage, it is likely that a greater number and variety of robots will be introduced and implemented in the future. While the benefits of applying robots and assistive technologies are recognized, the current limitations and weaknesses have also been identified. One of these is the difficulty associated with a user-centered design, involving older adults with impaired cognitive and sensory abilities in nursing homes. In order to overcome this challenge, a project was carried out to develop a soft and compact bedside communication robot with an input/output device, connected to existing technologies (e.g. monitoring camera, biological sensor). Drawing on the principle of gemba (deference to frontline professionals' experience, expertise and skills), users' feedback was reflected in the iterative steps of robot development. The original soft and communicative robot was introduced and its effectiveness was tested by measuring older people's reactions and changes in their behaviors and engagement levels. The article reports the development process and results of a small-scale evaluation study, comparing the impact of this original soft-type robot with and without its communicative functions. The human-robot interactions were captured on video, and the analysis revealed that while communicative robots reduced the psychosocial burden on older adults, positive emotional, verbal, visual and behavioral engagement was generated with the help of the non-verbal plush toy.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

Using huddles to improve communication and teamwork in an instrument-processing department

Instrument-processing staff work in a fast-paced, high-risk environment and errors in any of their processes can have a significant effect on patient safety. Effective communication is essential to the maintenance of complex processes such as the cleaning, disinfection and sterilisation of surgical instruments. This article details a service improvement project that aimed to evaluate staff members' perceptions of teamwork and communication before and after the implementation of team huddles in an instrument-processing department. A questionnaire was used to survey staff perceptions of teamwork and communication before and after the implementation of team huddles. The huddles included the use of a huddle board to standardise their content. While the survey did not identify any significant differences in staff perceptions before and after the implementation of the huddles, the department leaders noted significant improvements in the attitudes and engagement of staff members. The service improvement project demonstrated that structured team huddles can improve morale and efficiencies within departments through enhanced collaboration and communication.

Exemplars Illustrating De-implementation of Tradition-Based Practices

Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.