An interview with Ellen Noel, faculty member at Virginia Mason Institute
When you think about costs in health care, what costs do you think are hurting us the most?
EN: To me, the cost of a broken care system to patients and families is enormous. If a health care organization doesn’t have a system with reliable processes to help providers deliver the best care for sick patients, then they’re delivering defective care — and getting subpar satisfaction scores. Quality is top priority. Without that, organizations will experience patient and staff dissatisfaction, and the financial pinch of lower reimbursements will follow.
How does this kind of cost affect health care employees?
EN: It affects health care providers and staff in different ways. Highly trained, well-intentioned health care providers who work in a broken system have difficulty executing care for patients. When they find they can’t fix the system on their own, they leave, hoping to find a place where they can provide the best care to their patients. For any organization, losing staff is very expensive, and so is the cost of onboarding new staff to replace those who have left.
Waste is everywhere in health care — and the waste associated with defective care and the waiting due to chaotic processes have an impact on safety and quality. When staff have to do a process over because of a defect or error, it’s expensive for all staff members involved. It’s a waste of talent, time and money, with the potential to harm patients.
The waste of too much or too little inventory is another cost of a broken system that affects staff and patients.
How does inventory affect cost, quality and safety?
EN: Too much inventory can be seen as “sleeping money,” as supplies and equipment sit idle and unused. Insufficient inventory, on the other hand, causes staff to create their own access to “just-in-case” supplies and equipment because the organization’s inventory is not as it should be. Providers can’t move forward with a process if they don’t have the supplies they need. The safety implications are huge, the staff satisfaction implications are huge, and the patient’s length of stay increases. Working in wasteful systems is disrespectful for staff and patients, and normalizing this waste is costly to everyone.
“The key is transparency. Data needs to be transparent. It allows people to see what the errors are so they can fix the system together and prevent errors.”
– Ellen Noel
How can organizations make this better?
EN: The key is transparency. Data needs to be transparent. It allows people to see what the errors are so they can fix the system together and prevent errors.
Can you give an example of a way Virginia Mason has used relevant data to fix a problem?
EN: Yes. Several years ago, a young female patient had a stroke, and her mother was there with her during recovery. During service rounds, in which the local nursing director rounds with each patient prior to discharge, the patient’s mother was very direct. She said that communication between the care team members about her daughter’s rehabilitation treatment plan had not been going well and she was afraid it was greatly impacting her daughter’s care. “If the hospital and I were married,” she said, “we’d be getting a divorce.”
There were delays in getting her daughter to see a rehab specialist, a dietician, a physical therapist and a speech therapist, and she knew her daughter needed timely help to get better. Immediately, the nursing director triggered a Patient Safety Alert™ (PSA), an essential part of Virginia Mason’s Patient Safety Alert System. (At Virginia Mason, because all employees are empowered as safety inspectors, they are expected to contact Virginia Mason’s safety team about any incident that harms or threatens to harm a patient. That’s why even before the conversation had ended, the nursing director knew what she would do.)
As the director of quality and safety, I was part of the team that responded. I knew we had to better understand what was happening so we could improve our process for her daughter, for her and for all our future patients. The next day, a team of us came together for a one-hour session: me, the nursing director of the local unit, the nursing director of rehabilitation, a hospitalist, a rehabilitation physician, a social worker, a dietician, a nurse and the patient’s mother. We knew that by using lean methods and tools to study the symptoms of the problem quickly, we could find the root cause — and we did.
How did the lean tools help the team improve the process?
EN: As a team, with the mother front and center, we used a flow mapping tool to allow for rapid learning and root-cause analysis. This tool helped us engage all participants in the process and enabled us to identify process steps, identify the operators involved and understand the communication types and flow. It was clear by the direct and honest way that people were speaking that everyone in the room was skilled and had the best of intentions. It was also clear that the system had badly failed this patient and her mother. Together we discovered where the breakdowns in communication had occurred.
After this meeting, the team formed a kaizen plan, which is a sequential plan of process improvements. The sense of urgency and focus resulted in a redesign of our process, clear role expectations, and new standards for handoffs, communications and care coordination. This standardization allowed for improvements that respected the people doing the work and — most importantly — respected the patient and family. Using lean tools, everyone participated in the work to study, create, test and implement new processes that would improve patient care for the rehabilitative stroke experience.
Looking back, how do you feel about the way this process worked?
EN: After the PSA was called, an incredible team came together — including the patient’s mother — within 24 hours. It was a good day! And the patient’s mom was so happy to help us make care better. This was improvement work at its best, and I still see it happening every day. Leaders are rounding and really talking with patients, and patients are part of the teams that find sustainable solutions to make sure our care is safe, waste-free and of the highest quality for our patients.
Ellen Noel, MN, RN, CPHQ, is a faculty member at Virginia Mason Institute. Her in-depth knowledge of clinical processes, team development, health care outcomes and regulatory performance provides a solid foundation for an extraordinary customer learning experience. Prior to her work at Virginia Mason Institute, Ellen worked as an adult clinical nurse specialist and director of quality of safety. As an improvement leader, she led system-level improvement work in medication safety, nursing and care team workflow efficiencies, pain management and patient safety. Ellen is a Kaizen Fellow graduate certified in the Virginia Mason Production System®. She is also a Certified Professional in Healthcare Quality.