Using Lean to optimize clinical practice, staff satisfaction, and patient experience Pediatric Perianesthesia Unit Project Sara Woodbury MSW, PMP, LSSBB Kristen Young MSN

What was the problem? Too many pediatric patients were arriving in the OR without IV access established WHY were pre-procedure IVs not placed? No established standard for IV vs. mask induction High anxiety of pediatric patients & families Varying levels of staff expertise and confidence Misperception about mask induction experience

How was the problem identified? Nurse manager and anesthesiologist identified an opportunity to optimizing patient experience Operational Excellence was asked to help They wanted a framework for change—Lean

What were the goals? Establish & implement a standard of care Patients ≥ 8 y/o to have IV insertion care bundle Reduce defects (mask induction) Baseline: 37% Goal: 10% Improve staff confidence and enhance skills Optimize patient experience

What did they do? An interprofessional team was sequestered for a 3-day Rapid Improvement Event

How did they do it? Mapped the current state Identified root causes Developed countermeasures Evaluated and selected high-value solutions Managed the change with regular coaching and progress monitoring

How was the change managed? Scripting for all staff Daily Inter-team huddle Change management Leadership messaging Daily support available Weekly coaching from RIE leaders

What did the team implement? Visual management to reduce interruptions Flow of patients on white board Signs for procedure in progress Tactics to hard-wire the process Peripheral IV order in EMR includes numbing cream Comprehensive orientation to the new way Periop nurses observe mask inductions Brand the experience for all—the Lion’s Pledge

The Lion’s Pledge A Therapeutic Approach to Pediatric Venipuncture MD

What else? 5S the Supply Drawers Implement care bundle Use data to change par levels Move all IV supplies to one drawer Use picture to maintain proper order Evaluate par levels periodically—change if needed Implement care bundle Numbing cream Comfort positioning Therapeutic distraction

Not-So-Comforting Position Parent standing to the side, not engaged Hovering over the patient Patient forced to lie supine No one engaged with the patient Bed is too low, making it uncomfortable for staff inserting the IV Leaning across patient

Comfort Position: Parent at Bedside Parent engaged in support Patient permitted to sit upright Clinicians on separate side, at patient’s level Patient engaged in distraction Distractor on separate side

Comfort Positioning: Side Sitting Parent as distractor, book on opposite side of clinicians Clinicians on separate side, at patient’s level Patient distracted & held by mother Legs free to dangle

What were the results? Defects reduced—clinical practice optimized Staff satisfaction improved IV process is clear & easy to do Baseline 14% Post-RIE 85% Patient experience enhanced Weekly scheduled patients switched to IV induction They’ve developed new coping skills “I think I’ll have an easier time with lab draws now”

What was the impact? Patients Staff Organization Patients and families asking for this care bundle when in other PSH care venues “Frequent Flyers” ask for the “magic cream” Staff Increased skills and confidence with IV insertion Expressed appreciate for a standard to follow Organization 2017 Magnet surveyors recognized this interprofessional team and their framework for change Differentiates our Children’s Hospital in the region

What questions do you have?

Thank you! We welcome your feedback… Sara Woodbury swoodbury@pennstatehealth.psu.edu Kristen Young kyoung2@pennstatehealth.psu.edu