LHAC was right to express concern about a rate of nosocomial infection that already came close to 5% for this is a prevalent problem not only in hospitals but across all health care facilities as well. Vincent (2003) cited astounding morbidity rates of 30% of ICU patients, for instance, as well as many studies having traced the problem to certain patient types and the use of such invasive equipment as catheters. I decided on “inefficient equipment management” as the root cause because I was impressed by the disparities in equipment utilization across the different departments.
This suggested unsystematic distribution, itself the reason why nurses seem to spend more hours caring for each patient than planned. Mr. Watts congratulated me for identifying the correct root cause. His feedback in this regard did mention the variance in nosocomial morbidity across departments. I had noticed that, as well as the high utilization of invasive equipment in those departments evincing nosocomial infections at around 1% of total. Given this result, I would of course not have done anything differently. Establishing an Airway
I needed to choose enforced terminal cleaning as the primary process improvement because the leading cause of a nosocomial infection is always contaminated or improperly-sterilized equipment, particularly the invasive type. In one stroke, I achieve effectiveness, focus, reliability, efficiency, quality management and progress toward strategic aims. These advantages are demonstrated in achieving a JCAHO Compliance Index of 79. 1% right away at what seems to be a modest impact on adjacent processes (principally staff time).
So important is terminal cleaning in the management of nosocomial outbreaks that the authoritative protocols for the irritatingly widespread and persistent Acinetobacter spp cover thorough cleaning of beds, mattresses, railings, shelves, bathroom surfaces, utility rooms for both clean and soiled linens, mop heads and handles themselves, I. V. poles, wheelchairs, glucometers, and of course, all shared equipment (Johns Hopkins Medicine, n. d. ). By comparison, switching to all-disposable equipment is not as successful in matching JCAHO standards (77.
75%) and fails to make really efficient use of resources since it is not yet practical to source disposable versions of some equipment. So a process improvement that encompasses terminal cleaning of, say, forceps and ventilators, achieves quality objectives better and protects LHAC reputation more firmly. For the other improvement, appointing inventory clerks seemed the best possible option. Though this step causes considerable disruption in adjacent processes and absorbs the rest of the CFO’s budget, it maximizes compliance with JCAHO standards in terms of minimizing the clinical risk of equipment.
As well, it assigns responsibility for monitoring compliance with the primary process improvement, enforced terminal cleaning. Once again, Ian Watts sent kudos for identifying the optimal mix of steps for improving the LHAC equipment management process. However, the CEO evaluated my metrics set as correct solely for #3 below. I opted for these metrics: 1. Equipment incidents resolved (most critical for LHAC); 2. Total cost of managing equipment; and, 3. Utilization versus cleaning log ratio. I should have, it turns out, focused on “carrying cost of unutilized equipment” and “idle time”.
Benchmarking Partner I chose Florence Trauma Center as benchmarking partner chiefly in point of having the highest rating (70) on similarity to LHAC processes and owing to the prestige I associate with its winning the “Hospital of the Year” award. Rose and Ruth General Hospital matches Florence in all respects and makes a viable candidate, too, except that I was inclined to consider its Magnet award less prestigious and less likely to be remembered by inattentive patient-stakeholders than “Hospital of the Year”.
At the other extreme is “Touch and Heal”. Although this long-term and adult day care facility had the longest track record in managing the quality improvement process, the nature of its operations, size and ordinary accreditation makes it a poor match for LHAC. Ian Watts suggests that I misjudged the parameters and ought to have decided on Rose and Ruth as benchmarking partner. This required more attention to size in terms of number of beds, to maturity of process and to similarity in terms of therapeutic departments covered.
As well, the transient character of the “Hospital of the Year” award escaped me, as did the significance of the MAGNET award. It turns out that the latter is a quality-related measure, decided on by the American Nurses Credentialing Center, that recognizes the overall quality of inpatient care in terms of “nursing excellence and innovations in professional nursing practice” (American Nurses Credentialing Center, 2007). Process Improvement Strategies
I chose to draw down the equipment inventory at LHAC because of the observation that the largest performance gaps vis-a-vis Rose and Ruth had to do with utilization rates and, its corollary, carrying cost. Assuming that the patient load already maximizes usage rate of the existing inventory, a relatively low utilization rate some months after usage efficiencies were optimized can only mean that there is a substantial quantity that remains stocked and unused all or most of the time.
This is carried on the books as a carrying cost charge against current revenues, reducing net income and the cash flow needed to expand or to invest in other quality improvements. Watts agreed with me and pointed out how the correct choice of process improvement strategy would also bring down total inventory, as well as costs for repair and maintenance. This being the case, I do not need to do anything differently next time. Summary and Conclusions At the end of the day, the simulation led me through analysis and problem-solving of what appeared to be a complex set of problems at LHAC.
Perhaps the most gratifying aspect was to have fallen back on my medical science and management training to understand that the core process that needed attention had to do with inefficient equipment management. In my current job, this has heightened my awareness of being a skeptic about surface impressions and “anecdotal data”. Putting a foot wrong once or twice when exercising judgment about benchmarking partner criteria convinced me to pay better attention to relevant hard data, work through the cost and organizational implications of alternative process improvements, and to exercise better judgment about subjective information.
As well, I shall be more vigilant about variances both from norm and against benchmarks. The management of continued process improvement, I see, yields tangible results over the short and medium term. And it is, after all, a process that starts with root causes, solves for alternatives, optimizes matters for various stakeholders and continually takes on the many interrelated concerns they have with a health care organization. References
American Nurses Credentialing Center (2007, September 12) What is the Magnet Recognition Program©? Retrieved February 3, 2008 from http://www. nursecredentialing. org/magnet/. Johns Hopkins Medicine (n. d. ). Cleaning protocol for multidrug-resistant acinetobacter (mdr-ab). Retrieved February 3, 2008 from http://www. hopkinsmedicine. org/heic/ID/mdr/cleaning. html. Vincent, J. (2003, June 14). Nosocomial infections in adult intensive-care units. Lancet, 361(9374), 2068.