The Problem: Waiting
knew we had a problem when we saw that over the course of a few years, our internal costs had increased. Our process hadn’t changed much, but I had a gut feeling about what was causing the increase. As an organization, we decided to investigate.
The OBGYN department tasked medical director Brett Einerson, at the time a maternal fetal medicine fellow, to become the clinical leader of our childbirth value streamA value stream is the series of activities our patients encounter as they receive care.. A team assembled from across the patient’s value stream: prenatal care, labor and delivery (L&D), and maternal newborn care (MNBC), the inpatient unit where new moms and babies prepare to go home.
Five years’ worth of data and our process map revealed that patients were staying longer, specifically on labor and delivery. Everyone waited—nurses, doctors, and importantly, the patients:
"I thought I had an appointment to have my baby, but it felt like they weren't ready for me. Once I did get into a room, I waited a long time without any information. It made me wonder if they forgot about me."
The Bigger Problem: Culture
Our larger problem was our culture—it was part of our culture that a veteran nurse would wait on a brand-new resident physician to come up with a plan of care. I always practiced in community hospitals. In community hospitals, labor and delivery nurses are very autonomous because they don’t have residents. Here at University of Utah, we have a different model, where residents are very involved in patient careAcademic medicine has a three-fold mission: educating the next generation of health care providers, understanding and treating disease, and caring for patients..
While having residents and active learning is wonderful, it also creates challenges for the nursing team. Compared to community hospitals, I found our nursing team less autonomous and less able to practice at the top of their license.
Waiting was challenging for everyone—the nurse, the resident, and the attending physician.
Build a team
We started by analyzing our current state. We convened people from all different departments to help. Julie O’Neil from IT, Shirley Denicke from the call center, Jen Spackman from nursing informatics, Rachel VanMeeteren from the outpatient clinics, Brett Einerson, myself and Nikole Ihler, the labor and delivery clinical nurse coordinator.
We focused on when labor and delivery was the busiest. We tend to think that we can’t predict when a baby is born. But, when we started looking at years’ worth of babies, we began to see patterns.
We found that most deliveries occur during the day, between 8:00 a.m. and 6:00 p.m. There is a specific reason for that timing—we do scheduled inductions and c-sections during the day. The data was key to understanding our opportunity for improvement.
Scoping the solution
We focused on elective induction because that is the one part of our business that we can actually control. We can control when they come to the hospital, we can control when we start an induction agent for them. Everything else about child birth is harder to control.
Three Changes to Tackle the Delays
1. Changing the flow of patients (addressing one of 7 wastes)
First, we looked at the way we scheduled patients. For years, we had scheduled patients to arrive for their induction at 7:30 a.m. But, that’s a terrible time—shift change is at 7 a.m. Everyone is at the at the nurses' station talking about the night before or in patients’ rooms giving report. We realized that patients were waiting while nurses took care of other patients.
We ask the patient to arrive for their induction at 5:30 a.m. It seems very early, but we know that pregnant women don't sleep the night before anyway because they’re really anxious! Now, by the 7:00 a.m. shift change, the patients are all tucked in—no more chaos at the nurse's station.
2. Changing staffing
Before this change, we staffed the unit with the same number of nurses for both day and night. When we really dug into the data, we realized—we don't need 10 nurses on a night shift when we’re not doing many deliveries. We created new shifts and started stacking our staffing so we had more hands-on-deck when we had more deliveries.
3. Creating a standard induction plan (a type of forcing function)
Before this change, everyone waited—nurses, doctors, and importantly, the patients. We standardized the way physicians would induce their patients, so that experienced nurses didn’t have to wait for an inexperienced physician to launch an order.
This change empowered the nurses to practice at the top of their license. I wanted the nurses to practice at the top of their license and be able to use their critical thinking skills. In conjunction with the physician plan, we created a nurse order set in Epic so that a nurse didn't have to wait for an intern to launch those orders. The nurse could actually go ahead and launch those orders—reducing wait time for everyone.
As part of the plan, we set expectations for every person who is a part of the whole process. We wrote out expectations for the resident, the MA, the nurse, etc. It is now very clear who is supposed to be doing what, which reduces additional waits.
Before we started this work, it was very common for it take us 90 minutes to get an induction agent on board. Now, 85% of patients get their induction agent started within 60 minutes, which is the standard of care.
Empower the team: The expert is the person doing the work
I was not the expert because I had not been at the bedside for a very, very long time. We created committees of charge nurses and regular nurses. Literally, I just threw an email out there and said, "Here's what we want to do, here's what we want to accomplish. Who wants to be on the committee to develop our new induction schedule?" And then I had volunteers and they were the experts, they knew all the blocks that we would find. They knew what we would have to overcome.
Put yourself in others’ shoes
Before this project, there was a lot of finger pointing when there was waiting—"it's the resident's fault. It's the nurses' fault."
This project probably taught me the most about what it might feel like to be a frustrated nurse, just waiting for the doctor, or a brand-new resident who has no idea what he or she is doing, and being asked to come up with a plan of care.
We did a lot of education with the nurses and had many discussions about what it would feel like to be a new resident, and to remember - a little compassion, a little patience, a little teaching—goes a long way.
Working on this project not only created a more coordinated experience for our patients (and reduced cost) but also enabled me to help design processes that allow every member of the team to practice at the top of their license. It has helped me give our nurses a voice by valuing their expertise.