The key to solving problems in a large organization such as Cleveland Clinic is not to bring in people to fix things, but to empower caregivers with capabilities to solve problems on their own.
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Creating culture of problem-solving is a focus of Lisa Yerian, MD, Medical Director of Continuous Improvement at Cleveland Clinic.
Dr. Yerian is a steward of the Cleveland Clinic Improvement Model, which is changing the way caregivers approach their work. She and her team found that the best path to sustaining a culture of improvement is to provide caregivers skills and encouragement to solve the most pressing problems in their areas. This philosophy has proven to increase efficiency while improving access, quality, safety and the patient experience.
A look at the model
Cleveland Clinic’s model is based on the work and learnings of the thousands of Cleveland Clinic caregivers who have been engaged in building their “culture of improvement.” The model builds on practices made famous by Toyota. The automaker’s principles for empowering workers to continually improve their work have been adopted by other industries, including healthcare. Also included are other quality improvement methodologies (Plan-Do-Check-Adjust) and other concepts like goal alignment and high reliability. All described in simple terms that everyone can understand and embrace.
There are four key systems in this model. Problem-solving was the first created and a logical place to start for Dr. Yerian and her team. They have worked with about 12,000 Cleveland Clinic caregivers in nursing, finance, pharmacy and other departments, and at many locations. Physicians are engaged, as well as Cleveland Clinic executives. Coaching caregivers on how to identify and tackle problems, Dr. Yerian’s team emphasizes open discussions about problems, focusing on those that matter most and ensuring staff have time and the capability to work on improvements.
Everyone wants to solve problems
“Everybody has problems. Everyone wants to solve them,” Dr. Yerian says. “Our caregivers are blown away what they see what they can do if you give them the capability. They perform better and they’re happier. This approach is better for our patients. And it’s better for our caregivers.”
Teams now list problems on a board on the wall, and discuss priorities to be tackled. In a nursing unit, for example, caregivers were asked to identify waste or “what gets in the way” of doing their work. They talked about hand sanitizers and sinks not being conveniently located where nurses do their work. The solution was attaching hand sanitizer dispensers to the nurses’ portable workstations. This countermeasure saved time and improved hand hygiene. Also, engaging in problem solving boosted nurses’ morale.
And results are delivered
At the Home Delivery Pharmacy, a number of changes dramatically reduced turnaround times for deliveries, from 10 to 14 days to three days or less. After identifying problems and posting them on a board, the pharmacy team worked together on solutions. Going forward, they could chart their progress and successes on the large board, under the headings “new idea,” “working on idea” and “completed.” The team has sustained both their improvements and their culture for nearly three years.
Another team using this model delivers supplies to operating rooms. The team had a high turnover rate, but engaging the caregivers in making improvements resulted in improved efficiency and engagement. The team saw no turnover over the next three years and began to help other teams solve problems in their areas.
At the heart of the process is a “kaizen” board and a system for prioritizing problems into the straightforward “just do its,” more involved “root cause” problems, and the complex problems for which teams use an A3 problem-solving tool. An A3 report details the problem, the root cause, potential countermeasures and calls for consensus around a plan of correction. There are a lot of complex problems in healthcare. We do a lot of A3s.
As an example of its usefulness, the A3 process helped a nursing unit at Hillcrest Hospital improve patient response times by 23 percent, which resulted in a decrease in patient falls.
Sharing success with others
That success and many others under the Cleveland Clinic Improvement Model have received attention from the Lean Enterprise Institute, a Cambridge, Mass., nonprofit dedicated to lean thinking and practice.
In an article about Cleveland Clinic’s growing culture of improvement, the institute noted several other successes: An oncology team reduced outpatient chemotherapy wait times from an average of 60 minutes to 20 minutes. The emergency department also reduced wait times. The benefits flowed from improvements in the way work was structured and performed.
Dr. Yerian stresses the importance of daily conversations, or “huddles,” where teams talk openly about how they’re doing and what problems they’re experience. This year, tiered daily huddles have been initiated at all Cleveland Clinic hospitals, and they extend all the way to top executives.
“If there is a fall at a hospital today, tomorrow it will be discussed at every level in the team huddle,” Dr. Yerian said. “We want to find out why and how it can be prevented from happening again ― anywhere.”
“That’s a key component of problem-solving,” she said. “Making sure it’s discussed at all levels helps change not only happen, but actually stick!”