Doctor Talking to other with Hand on Shoulder | Virginia Mason Institute

Pain Huddle Leads to Less Medication, Lower Readmissions

Ellen Noel

From the front line to the boardroom, nurses are a valuable resource in solution-oriented health care. Their unique professional training and their role as advocates for patients and families along the wellness continuum make them essential to multidisciplinary teams that identify problems in health care and then work to develop sustainable solutions to improve care.

A 2010 Institute of Medicine report (“The Future of Nursing: Leading Change, Advancing Health,” October 2010) identified key messages to guide the nursing profession. Two of these recommendations are truer than ever today: Nurses should practice at the top level of their education, and they should partner with physicians and other health care colleagues to make meaningful change for patients.

Lean process competency enables nurses to do both. In organizations with cultures that encourage their employees to speak up with ideas and empower them to act, lean invites all levels to participate. Why is lean such a good fit for nurses leading change in health care systems?

  1. Lean is inclusive. When nurses meet with a multidisciplinary team that integrates multiple points of view, they can uncover the intricacies of a problem with a rapid, thorough root-cause analysis and devise a solution that can have a big impact on patients.
  2. Lean processes can enable nurses to scientifically and rapidly observe real-time health care delivery, analyze data, identify problems and focus the discussion. Because nurses work directly with patients in the exam room and at the bedside—and indirectly as they integrate evidence-based practice into organizational systems—they already understand the problems and processes at deep levels. While using lean processes, nurses are challenged to remove wasteful practices and make patient care better.
  3. Lean can enable nurses and their colleagues to create solutions to fix broken processes. They can use rapid-cycle learning to collaboratively develop plans of action and implement change. The patient is at the center of all they do, so they know that the end result can produce a new level of care with a value-added approach for their patients.

Case study: Introduction

Like other health care organizations, Virginia Mason struggled with the complexities of caring for patients with persistent or chronic pain. The patients with persistent pain could be dependent on or addicted to strong pain medications, resulting in long hospitalizations and multiple readmissions. Even more, the many components of persistent pain syndrome led to delays in discharge and care progression and greatly impacted patients’ quality of life.

The old system

When checking on a patient experiencing persistent pain, a nurse might say, “How are you feeling now?” and the patient would often respond: “I’m in a lot of pain and need more pain medication.” A pain assessment typically produced a pain rating of 10 out of 10, so the nurse immediately contacted a physician to approve more pain medication. Unfortunately, the physician’s busy schedule meant this couldn’t happen right away, and there were delays. In addition, the physician might be wary about increasing a dose of a medication that didn’t work or giving a patient more than was needed. Physicians needed time to investigate other ways that might help relieve patients’ pain, and meanwhile, the patients were in pain, feeling frustrated and angry. To make matters worse, nurses’ dissatisfaction with their jobs increased because despite all their efforts as patient advocates and caregivers, they couldn’t help their patients who were in pain.

Improvement work

A team of anesthesiologists, nurses, nurse pain specialists, hospitalists and kaizen promotion office (KPO) specialists met to redesign the hospital system to support patients with persistent pain. First, through a process of discovery in their Rapid Process Improvement Workshop (RPIW), they analyzed the multifaceted elements of pain—emotional, cognitive, physical and psychological. Using evidence-based guidelines and inviting patients to be part of the process, they designed a “wellness wheel” that focused on functional comfort and gave nurses, physicians and patients a starting point in the conversation about pain. Instead of simply talking about the feeling of pain, clinicians and patients talked about the factors that contributed to the pain experience: appetite, activity, sleep, plans for the day, mood and medication. All the components were featured in the shape of a wheel on a poster, so that the clinician could point to one factor at a time to guide the conversation, step by step.

Then the RPIW group developed a new “pain huddle” to accompany the wheel and practiced simulations, tested the huddle with real patients at the bedside during the week, refined their scripting, built assessment tools, and compiled and analyzed feedback.

Leaders—nurses, anesthesiologists and hospitalists—were key to the project’s success. They kept it alive and really made it work for the patients and the staff because they believed it would benefit their patients physically, cognitively, psychologically and emotionally. It turns out they were right, and the wheel is used today to guide these important patient conversations.

The results

The 30-day and 60-day metrics showed that after training, the clinicians found the wellness wheel intuitive and embraced it. Even more significant, the hospital’s multiple requests for additional pain medication began to decrease. At last, clinicians were able to use a tool, founded on the tenets of evidence-based medicine, to guide their conversations with patients in a way that embraced a fuller picture of the patient experience. Within 60 days of the workshop, proof of process sustainability was found in the electronic medical record as the teams continually referenced the use of the wellness wheel in their patient care plans. The results were included in patients’ medical records, and reports showed that patients were more satisfied with their care, needed less pain medication and were discharged earlier.

Because nurses are so critical to the patient experience, it made sense to involve them in the process to help relieve the problems associated with their patients’ persistent pain. The nurses on the team were proud to roll out the new tool, train clinicians and see the positive effects on patient care. Their engagement in the process not only contributed to the team’s success but also paved the way for a sustainable solution and a future pathway of continuous improvement.

To learn more about how nurses, physicians and other clinicians can use lean processes to improve care at your organization, register today for Lean Training.

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