At least half the battle in making and sustaining process improvements is getting the entire team on board with a new workflow. One key to getting buy-in from staff is to clarify why changes are needed and what the consequences may be if the new processes aren’t followed. In a recent Lean initiative aimed at reducing bioburden, OR leaders at the Mayo Clinic Health System Franciscan Health in La Crosse, Wisconsin, focused on delivering these messages, and as a result improved both workflow and communication.
In September 2013, bioburden on sterilized total joint instruments was becoming a problem at the facility. Bioburden was being found multiple times a day, sometimes reaching the sterile field and the patient.
At the same time, Karen Caballero Mathis, MSN, BSN, RN, was starting her job as director of patient care surgery. On her first day, she was invited to a meeting on Lean. Most of the organization had already been through Lean Management System training, and now it was coming to the OR, says Mathis.
“We decided to attack the bioburden issue with Lean,” says Mathis. “It was such a huge staff and patient safety issue, and it was important that we tackle it right away.”
A problem-solving team was formed that included nursing administrator, Kathy Moritz, MSN, RN, BC-NE; OR supervisor, Melissa Pellowski, BSN, RN; Mathis; Lean specialist Virginia Cosgriff, MS; and five staff members—staff nurse, Lynette Berg, BSN, RN; charge nurse, Stacy Picha, BSN, RN; surgical technologist, Joe Strittmater; processing technician, Julie Merzenich, and practice operations director, Michelle Neitzke, MSL.
“To find out what part of our process wasn’t working, we had to focus on one issue at a time,” says Cosgriff.
“We also knew we had to do something immediately,” she says, “so we implemented the application of an enzymatic gel to the instruments at the end of each case.” The gel adheres to all surfaces of the instruments and helps keep the bioburden moist while the enzymes start to penetrate for easier cleaning.
The next step was to educate the staff on the steps to follow when they identified bioburden on an instrument—ie, the surgical technologist removes the instrument and the instrument pan from the sterile field and then changes gloves.
“We realized right away that we didn’t have a good system for reporting bioburden events, and that events were being underreported,” notes Cosgriff.
The team used a Lean problem-solving A-3 tool to find the root cause of the underreporting. The chief problem was that the Midas reporting system software was confusing and time consuming.
The next step was a Lean 5-Why analysis, which asks why something happens five times:
• Midas is confusing and time consuming. Why?
• Why? Because staff don’t do it often?
• Why? Because the fields are confusing?
• Why? It times out—only on the screen a short time.
• Why does it time out? Because staff get busy and go away from the screen.
It is easy to go down a list of issues when a root cause analysis is done with 5-Why, notes Cosgriff. “But remember,” she says, “when you are doing your root cause analysis with ‘Why,’ it’s never a person, it’s always a process issue. You can’t blame a person for a root cause.”
The Lean standard work tool was used as a countermeasure to answer the “Whys.”
The team created standard work on how to:
• report a bioburden incident
• clean the key instruments that were causing the bioburden issues (total joint instruments)
• track incidents that had actually occurred
• track specific instruments found with bioburden to see if there were specific ones that were more problematic.
Standard work involves four key elements—who, what, how, and why. “When you have a ‘Why,’ people actually realize why they are doing something,” says Mathis.
Nurses are familiar with “Why” because they are used to writing a rationale in their care plans, says Cosgriff.
Adult learners need to know why they are doing the steps they are doing, she says. The processing staff didn’t know why they were doing the steps they were doing to clean and sterilize instruments. As a result, it was easy for them to skip a step because it satisfied everyone when the instruments got through the system more quickly for the next case.
“When they finally realized what each step did and why they did it, it was key to their learning,” says Cosgriff.
It is also important to have that “Why” when reporting an incident, says Mathis. Sometimes the answer is that it’s a regulation to report the incident, but the answer also could be it’s a patient safety issue or a defect for the person to whom the patient is handed off.
“It really helps staff understand the flow of things and that something they do can affect someone else or another department,” says Mathis.
Team member Berg developed a Midas report cheat sheet for the staff to help ensure standardized reporting (sidebar, above right). A checklist goes with the cheat sheet that says, for example, “if you find bioburden on this, then you choose this category,” says Mathis. “The checklist is very specific about what they should choose, which has really saved them time.” It used to take 12 minutes to complete a report, and now it takes half that time.
The safety cross is a visual management tool that is used to show the incidents that have occurred and the progress made through the Lean initiative (sidebars, p 17).
A key aspect of Lean is transparency, says Cosgriff. “We want to see every problem exposed, and try to fix it. The safety cross shows everyone what is going on, and it helps everyone be more aware that the problem exists and it is not okay to hide it,” she says.
The team implemented daily huddles to speed communication and involve the staff in daily problem solving, says Cosgriff.
“Make sure you discuss your operational things first but also include the improvements that you are making,” she says. “For example, start with what’s going on today—staffing for breaks, turnover issues, and add-on cases. Toward the end of the huddle, ask: Did we find bioburden yesterday? Did we have any defects that anyone wants to talk about? Are there any opportunities for improvements that anyone wants to discuss?”
It is important to have standard work for the huddle and complete the huddle in 10 minutes. After about 7 minutes, staff stop paying attention.
“I think it is the most value-added thing we have done,” says Mathis. “The staff get good information as well as their daily assignments at that time.”
However, she adds, some staff tend to become anxious when defects are discussed in a public forum, so leaders should note that the purpose of the discussion is joint problem solving, not finger pointing.
Standardization and accurate reporting of data in Midas helped identify further issues and questions. Among those were:
• Bioburden is still occurring after cleaning.
• Does the department have the right equipment?
• Does the department have adequate staff?
• Is the staff adequately trained and supervised?
By pulling together the Midas data, Mathis was able to write a request and show the need for two more sonic washers and a supervisor for sterile processing.
“It was a huge wake up for us and for staff to see the effects of their work,” says Mathis. “Taking the 6 minutes to report the bioburden in Midas actually ended up in an additional FTE and equipment.”
The WWW form was used to ensure follow up and reporting progress. The three Ws stand for What, Who, and When. This tool builds in accountability and the steps to take to work through an issue, says Mathis.
• What identifies the issue.
• Who identifies the person accountable for resolving the issue.
• When identifies when the issue was resolved.
“For example, we identified a problem with specimen management, posted the problem and person accountable, and the steps being taken to resolve the problem and when the problem was resolved,” says Mathis. “This approach allowed the staff to see where we were with the problem so we could move forward.”
Sustaining improvements is where the Lean Management System training comes in, says Cosgriff. “With a Lean Management System, you need tons of coaching to help drive the new behaviors you want, which also includes a lot of accountability that people are not used to.”
The key to sustaining improvements is standard work, says Cosgriff. “Without standard work, you are going to backslide. The standard work holds it in place so you can continue to improve.” ✥
Cosgriff V, Mathis K C. Reduction of bioburden in a surgery-based processing department. OR Business Management Conference 2015.
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