People with systems savvy understand technical and organizational opportunities, and have the ability to weave them together to do exceptional things. I read about Providence Regional Medical Center of Everett, Washington in a BusinessWeek article on innovation in healthcare and it was immediately clear to me that the staff at Providence practice systems savvy on a broad scale.
Kim Williams, the Chief Nursing Officer was kind enough to walk me through their process. Judy Espedal, a Cardiac Critical Care staff nurse, then gave me the history, and Dr. Jim Brevig, Director of Cardiac Surgery, the context. Their examples are valuable because they give hope for healthcare innovation, they show us an exceptional process over a long span of years, and they help us see technology tools beyond computers and email.
This is a two-part story: In this post, I'll describe one innovation in detail; in the next post I will look at their approach as an overall practice of systems savvy.
Providence Regional had been an early participant in "fast-tracking" routine cardiac surgical patients (e.g., patients with scheduled by-pass surgeries). Patients in the fast-track program would spend the night following surgery in the Cardiac Critical Care Unit and change rooms next day to the "step-down" unit to begin monitored recovery and rehabilitation. This quick transition to rehabilitation supports faster recovery and shorter hospital stays. Twelve years ago this was an innovative and successful program, but as the hospital grew and the patient load increased, they began to see problems:
Kim Williams: [We're] fairly proactive about how we manage patients and look at processes. We noticed that after the night shift nurse helped the patient up and the day shift nurse helped them to the room's recliner in preparation for transfer, sometimes a bed [in the step-down unit] wasn't immediately available.
Judy Espedal: I was noticing that patients were staying in the recliner for 4-6 hours waiting for their bed. By the time they did get to their room they were exhausted. The therapists assigned to them were gone for the day and patients weren't receiving respiratory, physical, or occupational therapy until the next day thus missing out on 24 hrs of care. We are Critical Care nurses, not physical therapists. We didn't have the practices built into our routines to get them moving [important for faster recovery]. We didn't have the tools to walk them -- they were hooked to everything. [Around 2002] I had a hallway conversation with Jim [Dr. Brevig]... "they are missing a whole day." By the time they get their new room, get in bed, and the new nurse assesses, it's 4pm. They are missing a whole day of walking and other therapy.
Dr. Brevig's response: "What can we do about this, Judy?"
Judy Espedal: So that's when we started. We formed a task force to brainstorm ways to get around this. "Is there some way we can bring the care to the patient?"
That's the origin of their Cardiac Surgery Single Stay Unit (CSSU). In a single stay unit the patient stays in place while the care and equipment come to them. The nurses, patients, and families have a single location that is changed to meet the patient's needs. Kim Williams notes that they have portable X-rays, smart pumps (for medication), and telemetry units for each patient. As the patients improve the staff moves the equipment out to make the room look like the patient is getting closer to home. Judy Espedal describes it as "family centered care." They didn't implement this approach on a whim, but based on data, and more data.
Before asking for a pilot program Judy Espedal, Dr. Brevig, and representatives from hospital administration, the partner step-down unit, and respiratory therapy visited two hospitals that had implemented single stay units (though not for cardiac surgery). The team brought back impressions and outcome data from the other hospitals. Following the presentation of this material, Providence gave them two of the unit's beds and permission to pilot the single stay approach for three or four months. They brought in portable monitoring equipment to let them extend their capabilities and added training for the nurses around how to switch from critical to rehabilitative care as the patient's needs change.
Note that they had to weave together technology and practice: A single stay approach needs technology that is portable and staff with a broad range of skills to manage the different stages of care. While you can renovate to support the single stay (Impacting Patient Outcomes Through Design, pdf, Katherine Kay Brown), the Providence team found ways to work with what they had. Kim Williams believes single stay can work in any room with a toilet (yes, room architecture is a technology!) -- meaning most hospital rooms could be single stay rooms if the other technology and practice adjustments are viable.
Judy Espedal says patients and families are now working with the same critical care nurses from admission to discharge. When a nurse can focus on the same two patients over days it allows for better care. "We can think of everything. We can get in an extra walk... sit with family... time to look at whole picture." Dr. Brevig notes that information transfer across the team is also improved given their twelve-hour shifts: The increased rapport given contact time with patients and family means that subtle, tacit knowledge transfers more accurately -- and only one “hand-off” takes place per day, rather than the two that would be required if the shifts were eight hours. Less opportunity for critical information to be lost.
The result of Providence’s ability to restructure based on technologies at hand, training to increase the breadth of nursing skills, and adjustments to patient care: Success. They decreased the time patients spend in the hospital by approximately a half day, have 99 to 100% satisfaction ratings from patients and family and numerous awards for the unit, and receive numerous requests to tell their story to other medical providers.
Is this evidence of systems savvy or just a lucky outcome?
Given they've made a variety of similar transformations over the years -- I believe the staff of Providence Regional Medical Center are demonstrating full-on, team-level systems savvy. In Part 2 I'll describe two more of their successes and summarize what I see as foundations we can all use.