Quality tools for Nursing care improvement

The nursing team plays pivotal role in any Hospital besides clinicians in overall patient care. The patient must be able to trust nurses with their lives and well-being. To validate the trust, nurses have to provide good nursing care and respect human life. In any typical tertiary care hospital more than 30 % work force are nurses’ .The nurses indeed form backbone of healthcare delivery in Hospital. Although primary role of nurse is to spend time in patient care, practically in most of the hospitals it is noticed that they spend most of the time in administrative work like   coordinating with other functional departments, documentation. The nursing workforce iteration is also very high compared in Hospital in any Indian Hospital. It becomes challenge for nursing head & team leaders to maintain consistent quality in critical processes   like pain management, medication management, infection control .Team leader should emphasize on nursing services quality improvement initiatives and ensure proper data collection, analysis, reporting and initiate changes wherever necessary.
The seven quality control tools will help nursing team to solve any practical problems and explain the problem & solution in better way to their team member & management. Each one of the quality tools given below is simple to understand & does not need statistical competency. The table 1 given below provides brief explanation of each quality control tool & its usage in problem solving.

The following case study was carried out in patient single room patient ward in tertiary care Hospital based on patient feedback on concerns raised in delay in attending patient calls by nursing team. The Hospital has installed nurse call bell for each patient room and in the patient toilet. The patients are informed to contact nurse by pressing nurse call bell.The nursing team leader with staff studied the existing process by doing time & motion study for 100 samples for one week at different time slot. The non-conference or defect was considered for those calls wherein nurse attends patient after 30 second.          

   The flowchart shows the macro level process for patient using nurse call bell. The check sheet shows number of non-conformances is used by nursing team while doing taking samples. The histogram shown above provides information about number of patient calls attended within range of time in seconds. It is noticed that 12 out of 39 non-conformances have taken more than one minute for nurse to attend patient. The prominent reasons for non-conformance is mainly due to nurse being busy in attending other patient or busy with administrative work like indenting medicine to patient through Hospital information system, informing housekeeping on cleaning issues etc.

The brainstorm

ming session by nursing team using fish bone chart has resulted in surfacing out issues as highlighted in chart like deployment of bed to nurse, maintenance of bell, proper communication etc. as is shown  in picture.

 Each cause are carefully analyzed by team like experience of nurse with respect to delay using scatter diagram. As seen in the diagram given below, there is negative correlation between non-conformance with respect to experiences.   

The team after generating ideas addressed all points pertaining to nurses training like soft skills, technical skills; increased nurse strength from 6 to 5 per occupied beds after it was presented to cross functional team. The request was made to management for ward manager to take responsibility like discharge follow-up with other department, maintenance & security issues in ward etc. The Hospital team could not change nurse station location as it impacted major MEP (Mechanical, Electrical & plumbing service). The overall impact of this project helped nursing team to improve the service to patient. The control chart shown above is used to monitor the overall progress in status on bi-weekly & monthly basis for subsequent review.

The application of Toyota Lean way principal at OP pharmacy in Hospital

Being part of service industry, the meeting the expectation of patients is prime importance for any hospital. The patient centric approach to all clinical and non-clinical processes should include more value added activates for which patients are willing to pay & is done correctly in first time.

 The Hospital OP pharmacy is located in main lobby at ground floor and is open round the clock on all days. The out patients department is located in ground and first floor of the building. With patient footfall increasing on monthly basis, the average prescriptions received on any working day is more than two hundred.

The challenges:
 The patients were not happy with the service offered by OP pharmacy. The patient satisfaction rating of service of OP pharmacy was less than 60 % .The major feedbacks from patients were long waiting time, non-availability of drugs, poor response from pharmacy etc.
 The patients had to wait for longer period to fetch the medicine. The dispensing time of medicine was inconsistent. The non-formulary medicines were prescribed by hospital clinicians.

 The quantity of inventory beyond sixty days was more. The number of stock out & follow-up to procure medicine was not streamlined. The OP pharmacy team along with quality team started working on the process improvement at OP pharmacy. The quality team adopted Genchi Genbutsu, a lean tool to visit OP pharmacy to see actual situation on ground.
 The Ohno circle tool was followed by quality yielded following major observations from outside the OP pharmacy counter.
 • The automated Q- Management system was not functional properly as same counter was displaying two tokens leading to confusions.
 • The signage of process to collecting token & waiting for patients turn was not properly displayed leading to lot of Muda i.e. waste as most patients used to disturb the staff at OP pharmacy counter.
 • Counter four was not commissioned & no Q- management was put across counter.
 • The smaller denomination currency was mostly not available at OP pharmacy leading to delay in dispensing medicine.
 The similar exercise was done by quality team inside the OP pharmacy and it had resulted in following major observations.
 • The inconsistent method of medicine dispensing at different counters.
 • No quick action was initiated for any item not available at pharmacy.
 • The issue counter was cluttered with unnecessary items.
 • The orderliness of medicine in some area was not in logical sequence & no visual signboard was present in some places.
 • The inventory of more than sixty days was held for slow & non- moving items.


The process:
 The complete as it is process mapping was done by quality team. All the patient feedbacks were closely studied. The takt time was reviewed with respect to present dispensing time at various time duration to match the staff pattern. A strong need was felt by team to improve the visual control for OP pharmacy.
 The 5 S workshop was initiated to staff in OP Pharmacy. The patient feedbacks, present processes, bottlenecks were brainstormed as part of the workshop. The suggestions from team members were taken .The quality team studied each stage of S on ground along with pharmacy staff to know gaps and scope of improvement.
 The table below shows the steps initiated as part of 5 S measures. Around twenty five initiatives were taken up for implementation. The keshikomi chart as part of Oobeya project management was adopted for timely completion of the project.


 The team encountered a lot of practical hurdles like breaking old habits of staff, delay in getting work done from other supporting departments like engineering, housekeeping. The repeated persistence of team to excel had started giving results. The senior management was very supportive in entire initiative and repeated visit from management team further motivated the pharmacy staff to quickly adopt 5 S in their office.

The results:
 The visualization & accessibility of all medicines by staff increased with introduction of         5 S.The space is efficiently utilized both inside & outside the OP pharmacy. The inventory management improved including reduction of stock-out, expired medicine inside pharmacy. The patient waiting time has reduced due to realignment of space & items, standardized work flow. The patient satisfaction had increased post lean initiative at OP pharmacy as given in graph below. The environmental conditions are properly monitored and there is process in place to regularly check the stocks of desired items.

Conclusion:
 The lean initiative has helped the hospital to improve the patient experience, increase working standards & reduce the unnecessary inventory.

 Meaning of Japanese terms
 Genchi Genbutsu: To go & see, check
 Ohno circle tool: Standing inside circle
 Muda: Waste
 Takt time: It is the average unit production time needed to meet customer demand
 Keshikomi chart: Message board containing pending activity
 Oobeya: Big room for visualization, project management
 Seiri: To sort
 Seiton: To store/arrange
 Seiso: To shine
 Seiketsu: To standardize
 Shitsuke : To sustain•