We have all heard the safety instructions prior to takeoff: Put on your own oxygen mask first, before helping others around you. However, as nurses and caregivers, we are often so busy helping those around us that we don’t even think about applying our own “oxygen mask,” or what the cost is to ourselves when we don’t.
It is easier to focus on accomplishing the “to-do” list of our professional lives, especially at the bedside: Assessing and reassessing our patients, administering medications, charting, reporting off, communicating with physicians and support staff, working with equipment and supplies, educating our patients and families, and preparing for our next case or patient. It can feel as if we are barely keeping our heads above water.
I witnessed this firsthand as the director of a free-standing pediatric ambulatory surgery center in Pittsburgh, Pennsylvania. We were experiencing a period of record patient volume simultaneously with an all-time high in staff leaves of absence (LOA) in the postanesthesia care unit (PACU).
When you are challenged to work lean, even one LOA can stress the system, but multiple leaves coupled with over 5% growth year over year not only stressed the system, it stressed the staff past their ability to “just get the work done.” Staff were stressed at the start of shift and drained by the end of it. Everyone was aware of the problem, but with no additional positions immediately available to us, the way forward was unclear.
Fortunately, I had a PACU staff member, Angela Poznick, who was motivated by this staffing challenge, rather than drained by it. We worked together to identify a plan based on the Plan-Do-Study-Act (PDSA) Model. The PDSA Model, also known as the Shewart Cycle or the Deming Wheel, is a continuous improvement tool. It is used consistently by organizations following Six Sigma or Lean principles as a test of change—by planning it, trying it, observing the results, and acting on what is learned.
This is the scientific method at the bedside! We especially liked it because it considers both our internal customers (bedside staff) and external customers (patients and their families, and surgeons/anesthesia providers). For this model, the customer defines quality, and to achieve any success, we needed to involve the customer.
What was uniquely attractive about implementing a project using this model is the initial focus on observation. In order to implement it, you have to have an accurate assessment of what is currently happening. It is a “boots on the ground” approach that requires leadership to be present at the bedside as the processes are occurring. We needed to see how our staff were performing “in the thick of it.”
What impressed me most in my initial observations was the staff’s team focus. If staff felt like a colleague was sinking (and they did feel that way, pretty regularly), they expended a ton of extra energy attempting to help, not realizing the burden that their overcompensation was actually causing them. It was the opposite of those safety instructions on the airplane: The staff weren’t even thinking about applying their own oxygen masks, only offering them to others. This led to decreased engagement with the work and, eventually, to some senior staff looking for other employment opportunities.
The first step in the PDSA process was to ask staff what their current process was and what a better process would look like. Nothing was off the table—we wanted to hear all their ideas and suggestions. Staff had plenty! The quick suggestion is always to hire more people, but as all managers know, obtaining extra staff can often mean multiple justifications and a years-long plan. Once staff received the message that we had to focus on our processes to make changes now, they were off and running.
Staff identified what they felt were barriers to providing optimal patient care in our PACU:
Opportunity #1: There needed to be better communication from and control of the OR flow.
Improvements: Angela worked with staff to develop a formalized “OR Hold” process that started by having the OR staff calling into the PACU for a bed space with approximately 5 minutes of lead time before the end of the case. This gave PACU staff the opportunity to prepare for their incoming patient. If no Phase I beds were immediately available, or if there was no room on Phase II to move Phase I patients, OR staff would hold in place and PACU staff would alert Pre-Op to hold patients from going back to the OR so leadership could do an overall flow assessment. While surgeons were initially resistant to the OR Hold idea, we found over time that it afforded a better assessment opportunity, and holds became predictable based on scheduled services and patient mix. The predictability allowed for a better staffing plan, which reduced holds overall. Over the course of one summer, we went from several OR Holds per week to one or two per month.
Opportunity #2: Staff needed to feel less rushed in their Phase II discharge teaching with families.
Improvements: Initially, our PACU nurses were not assigned specifically to either Phase I or Phase II; they just took patients as they came out of the OR and gravitated to one side of the PACU or the other throughout the day. This rather chaotic plan was reinforced by the lack of physical barriers within our PACU—Phase I and Phase II are located within an open space, separated only by a nurses’ station. But because that was the way things “had always been done” at the surgery center, staff initially resisted a more specific staffing plan. First, we created a defined separation to the staffing of Phase I and Phase II. We strongly believed that keeping staff to one assignment would allow them to focus their energy and time on the patients, rather than dividing their time between their patients and colleagues who needed help. Over time, staff got more comfortable with this division and were able to focus on their discharge teaching—particularly when they could see the way each assignment was a necessary link in the chain of patient experience and flow.
Opportunity #3: Staff wanted a point person to manage what could be minute-to-minute issues in the busy PACU, and they wanted to feel supported in their communication with the surgeons and anesthesia teams.
Improvements: Since joining the surgery center in early 2015, I was convinced we needed to find a way to implement a leadership structure for the PACU staff, but until this project I hadn’t found a way to do so. Once Angela formalized the Phase I and Phase II staffing and implemented the OR Hold process, we saw the opportunity to implement a PACU Charge nurse model. Staff no longer felt like they were drowning, so they were better able to articulate what a PACU Charge nurse would look like for the surgery center. One of their most pressing concerns was the ability to access an advocate for staff on busy days, with patient or parent or surgeon issues, or simply as their primary go-to when issues needed to be escalated. Angela once again stepped up to outline the primary functions of a Charge nurse role, and she was also our first prototype.
Opportunity #4: Staff wanted their team focus to extend to our OR staff and the physicians.
Improvements: Once the Charge nurse role was established in the PACU, the staff not only had a formalized advocate for the patient, family, and physician issues, but also a lead “ambassador” to the OR staff. Angela began attending the daily OR morning huddles to better disseminate issues to her staff and to share the developments that were happening in the PACU with OR staff. Rounding throughout the facility became an important role expectation for both the OR and PACU Charge nurses. This increased interaction helped to break down some long-established barriers in the facility’s “us” vs “them” mentality. One of the important take-aways for us from this project was the importance of understanding the roles that everyone plays in a surgery center and how they contribute to patient flow and our patients’ experiences of the facility.
Angela and I focused on making one change at a time, evaluated its effect on the overall process, and solicited staff feedback. Then we either adjusted the plan or built on it. Our goals were to keep moving forward, build momentum, and achieve staff buy-in that the processes were making a real improvement.
Once staff began to see positive results, Angela and I started seeing glimmers of hope that these changes would stick. Once staff felt supported by unit leadership in making these changes part of the PACU culture, we began receiving wonderful words of encouragement.
Once we had established this model, we continued to reexamine ways to improve and refine our processes. The most important step is repetition: Processes that work must be repeated until they become part of our culture. No matter how many nurses call off, go on leave, etc., we must keep reinforcing our new processes. To that end, we maintain open communication with the staff through regular huddles, emails, and formal meetings.
Our evaluation of the processes is ongoing. In addition to unsolicited staff feedback, we’ve seen increased engagement scores on recent hospital-wide surveys. All staff, including OR nurses, report feeling better able to provide safe, quality patient care because of these improvements. Surgeons have been supportive; they have commented on having a “smoother” run of cases with less interruption in their days. Our anesthesia teams have been supportive. One of our initial goals was to better serve the needs of all our customers, and that seems to have been accomplished.
Observation of what was really going on in the PACU and what staff were doing to make the day work was invaluable. Our staff have high standards of care and high standards for themselves. They will push themselves farther than even they realize to get the job done. My biggest take-away from this project would be to talk directly to your staff as an initial step of problem-solving, because numbers and metrics don’t always tell the whole story of what it is like for them at the bedside.
We don’t want to lose focus on what’s best and safest for the patients—that’s obviously our North Star in healthcare. It is, however, incumbent upon managers to recognize when processes aren’t working or that staff are burning out, and to turn that acknowledgment into action. The staff are your customers, too, and they can just as easily vote with their feet.