Leaning Out the Nursing - PowerPoint Presentation

Slide1

Leaning Out the Nursing Policy and Procedure Process

Paula F. Coe MSN, RN,

NEA-BC

Director, Center of Nursing Excellence and

Innovation

Gregory M. Gurican RN, MS, MBA

Manager - Nursing Quality Management & Innovation, Center for Nursing Excellence and Innovation

Application of L6S ToolsWhat We Learned:Value Stream Mapping: (Eliminate Waste

)

Interview Stakeholders

5-S

: (

sort

, set, shine,

standardize

, and sustain)

SIPOC

:

Supplier, Input, Process, Output, and Customer (defining values)

A-3

: (defining the issue, background, current conditions, problem analysis [

5 Why’s

], setting a goal, targeting the new state, overcoming barriers, and determining the implementation

plan.)

The Issue (Value to the Customer)Significant delays in the distribution and posting of newly revised or created Nursing P&Ps to the INET. (n= 400+ )

Annual review of nursing P&P per DOH and other regulatory bodies as applicable

Delays in posting up-to-date Nursing P&Ps can potentially affect:

Patient care

Patient safety

Regulatory Compliance

Staff

/

Policy owner satisfaction

SDM Council efficiency/effectiveness/workflow

Key PointsCurrent process is inefficient and flawed and not workingSources of Waste: Multiple handoffs (process time) Duplication of efforts Multiple reviews Time delays (caused by re-work, tracking changes, reminder notices, log keeping)Multiple manual operations

Work-

arounds

by policy owners

Costs (color printing, hard copy distributions, time)

Policy Review & Approval Process

Notes

:

1

. Consolidate like policies when able.

2

. Delete non-applicable policies, requires Council approval.

3

. Job change requires re-assignment of Ownership.

Processing ReviewsInterviewed CNS policy owners and solicited feedbackInterviewed SDM council chairs for feedbackInterviewed current administrative supportMonthly distribution of all policies requiring review per ADM 001Number of Policies assigned to specific owners

Actual Process Flow

No. of Nursing P&Ps for Review

Distribution of Nursing P&Ps

5 Why’s….Delays is Administrative Processing of Policy and ProceduresLack of standardization without clearly defined role responsibilities and expectations across owner and councilsEach owner and council used a different method to process changes and communicate changesWasted time identified in the multiple processing steps

No standardization in formatting of documents by owners and administrative support staff

Waste in P&P Processing…..

“Where are we at in the process of the nursing policy review?

Nursing P&P Process SIPOCS

I

P

O

C

Supplier

Input

Process

Output

Customer

Nursing

P&P Owners

Council

Approvers

Administration / Management

Service Line CD

Proposed NEW

POLICY Owner

ADM-001 Nursing P&P Manual – “

Table

of Contents

”

Procedure Listing

ADM-002 Nursing P&P “Format & Content” Template Doc

Owners recommendations

Reviewers recommendations

Council

Chairs

recommendations

Management recommendations

MULTIPLE PROCEDURES GOVERN THE PROCESSES:

ADM-002

“Format & Content” Template Doc

ADM-003 Nursing P&P “Development & Review” policy

ADM-004 Nursing P&P

“Database, Access & Maintenance” procedure for storage, and retrieva

l

Revised and

Updated Nursing P&P Change Processing

:

Policy

Guidance

Format & Content

Processing of Changes

Review & Approvals of Changes

Staff

RN’s

Management

Councils

Leadership

Regulatory:

DOH

JC

External

Reviewers:

ANCC /

Magnet

A-3 AnalysesIssue: The current processing of Nursing P&Ps is backlogged 6-mos., which could lead to potential errors in clinical practice.Background: The existing cyclic process involves the handling of > 400 policies for review and revisions annually. On average 35 Nursing P&P’s must be reviewed monthly by policy owners, councils and administrative staff. The cycles include multiple communication paths, which generate delays in finalization of procedure changes and ultimate distribution and/or posting to the INET

Current Conditions:

W

aste is created throughout the process due to the multiple steps involved and

multiple individual processes led to lack of standardization which continued to delays and backlogs to increase.

Problem AnalysisFlawed communicationsWasteful tracking of administrative steps,Lack of timeliness due to nature of monthly review cyclesPoor spread of workloads over annual review periodOverload of owners and councils related to uneven distributions,Lack of standardization, without clearly defined role responsibilities and expectations.

Targeted Conditions

Solutions- Final ThoughtsNursing Policy regarding review process revised to reflect current workflow and standardized template implementedStreamlined Process flow and handling will reduce time delays and improve efficiencies and staff satisfaction

Evaluate proposal for system wide implementation of Mosby electronic P&P’s

Evaluate Policy Center SharePoint Portal for WellSpan Nursing specific policies