Changing Culture Through Experience: Eliminating Variations in Nursing Practice to Decrease Threats to High-Risk Infusion Safety

An interview with Ellen Noel, faculty member at Virginia Mason Institute

In your experience, how does culture influence lean improvement work?  

EN: A few years ago I had the privilege of representing Virginia Mason as a presenter at a National Association of Clinical Nurse Specialists annual conference. The topic, one of grave importance, revolved around nursing practice and the safe delivery of high-risk intravenous infusions in the inpatient setting. Health care providers, including registered nurses, are keenly aware of the risks associated with medications given to rapidly stabilize a patient’s blood pressure, sedate patients receiving ventilator support, treat blood clots and decrease pain.

I spoke about Virginia Mason’s lean work, which supports and accelerates safety improvements by engaging staff in problem solving. Early on in our 15-year lean journey, our strategic plan contained our cultural construct — which is still our true north — to put the patient first and deliver defect-free care in all that we do. So at the heart of our high-risk safety initiative was our belief that perfect care delivery is possible.

Why did Virginia Mason focus on high-risk infusion safety?

EN: As the Institute for Safe Medication Practices points out, high-risk medications pose a high risk of significant harm when health care providers make errors in administering them. And we know that administering high-risk intravenous infusions are error-prone events. Advancements in smart pump technology and the electronic medical record have significantly contributed to reductions in administration errors, yet technology alone cannot mitigate all defects.

How did Virginia Mason design improvements?

EN: During a retrospective review of our patient safety alerts (PSAs) related to high-risk infusions — which showed us our staff members’ reports of errors, near misses and potential threats to patient safety — our team saw the limitations of automation and information flow. Despite a well-established electronic medical record, smart pump technology and evidence-based policies, our internally reported PSAs showed substantial variations in nursing practice and a defect frequency of one event occurring every nine days. Although our analysis showed that no serious events had recently occurred, the frequency of reported events was alarming.

If patient harm was to be avoided, then our team needed urgent redesign, robust staff engagement and decentralized training in high-risk infusion administration. The aim was to leverage collective nursing knowledge to redesign high-risk infusion nursing practice, focusing on critical safety elements that were easily understood, precisely executed and reliably observed. The chief nursing officer requested mandatory training of 527 inpatient RNs within 90 days, and the training needed to be budget-neutral and occur within the nurses’ daily workflow. Without lean tools and techniques and a structure that supported problem-solving engagement, this request would have been unreasonable and unsustainable.

“Early on in our 15-year lean journey, our strategic plan contained our cultural construct — which is still our true north — to put the patient first and deliver defect-free care in all that we do. So at the heart of our high-risk safety initiative was our belief that perfect care delivery is possible.”

– Ellen Noel

What lean tools and techniques did your team use?

EN: The clinical nurse specialist performed a root-cause analysis of infusion errors, sharing the data transparently with the nursing cohort and leadership. The team sorted the defects into groups, and the Pareto analysis showed that defects occurred during infusion administration, which was directly within the wheelhouse of nursing staff. The Pareto analysis also showed that if five critically important steps were executed for each high-risk infusion event, 84 percent of the errors could be eliminated.

Meaningful data and transparency of results enabled a dialogue where the problem was made transparent and the people doing the work helped design, test and simulate solutions. After 14 simulations that included testing in various hospital settings, the team agreed on a standard and documented it, and the training began.

Taking the form of a train-the-trainer model with unique training attributes, the team focused on the five important steps that threaten a safe infusion and used the Training Within Industry method to train nurses in a high-risk infusion safety check, with demonstration and validation to ensure the check was executed correctly, safely and consistently. The nurses who did the work created and tested the standard work of a sequenced, repeatable and observable event. Using an economy of words and movement, the team developed training that took less than 20 minutes for each training session and allowed for on-the-job instruction and validation within the nurses’ workflow. House-wide training included support from master and unit-based trainers with the message that our people are our asset and our ill-designed system for delivering high-risk infusions trips us up and threatens safety.

What were your outcomes?

EN: Ninety-day follow-up showed initial training for high-risk infusion safety was completed for 98 percent of nursing staff. Additionally, skill validation was completed twice for 90 percent of all trained nurses. An eight-month follow-up showed a 75 percent reduction in reported PSAs related to high-risk infusions.

What did you learn from this lean improvement strategy?

EN: I learned that targeted root-cause analysis and scripted, standardized training resulted in observable changes to nursing practice and a reduction in patient safety alerts. Also, formal practice simplification improved training efficiency and utilized resources responsibly. Job-instruction techniques that leverage staff engagement through tactile, visual and auditory learning and are validated with repeat-back demonstration methods can alter practice patterns and positively impact outcomes.

Did this work influence the culture in a meaningful way? 

EN: When I began my registered nurse career in 1986, I experienced what happened when mandated policies and practices were delivered to nursing staff without the slightest consideration for what the frontline staff can offer in the process improvement arena. My experiences at Virginia Mason using our lean improvement method are quite different than the well-intentioned — yet ineffective — mandates of earlier days. My experiential takeaways for developing a learning culture hinge on the discrete and consistent experiences that are positive, relationship-based and built on respect and inclusion. Gathering meaningful data, sharing findings with respect and transparency, leveraging solutions through staff engagement and rapidly, and iteratively testing, refining and documenting agreed-upon standards build the gateway to improvement sustainability.

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.

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