strives to identify quality processes that correct the identified defects in a system .
● D Define opportunity for improvement , project goals , and patient requirements .
● M Measure pharmacy and medical supply consumption , overall cost and performance .
● A Analyze the consumption data to determine root causes of variation and poor performance ( defects ).
● I Improve process performance by addressing and eliminating the root causes .
● C Control by building a system of checks and adjustments for ongoing improvement in the 5-Ps through defining current work and application of standard work to achieve the designated goals .
Applying Lean for Healthcare within Infusion Therapies
A Lean Six Sigma program begins with mutual agreement and consensus of the stakeholders from supply chain , pharmacy and in this example , the vascular access team . Provision of intravenous therapy through peripheral or central catheter access are necessary for more than 90 percent of acute-care hospital patients . The delivery of intravenous therapy requires skilled clinicians , procedures and the use of supplies and technologies . The bundle and five components , representing improvement practices and supplies , was identified through research literature review with moderate to strong evidence . Analysis of the published evidence produced a peripheral intravenous catheter ( PIVC ) insertion process which included a 10-step PIVC insertion and five-step overall bundle for application as standard work . Incorporation of the 5Ps of Process , Protocols , Practices , Products and Patient Outcomes into intravenous ( IV ) therapy for insertion and management of vascular access provides a basis for decisions . This process uses the 5Ps as a tool to assist to differentiate the value-added actions from the non-value-added actions . In using 5Ps systematic approach waste and variability become obvious and detectable .
The Lean Six Sigma DMAIC method was used to specify standard work for PIVC insertions and best practices for PIVC management . This defined the Experimental Group method with application of the standard work in the PIV5Rights bundle . To maximize value and eliminate variability and waste , leadership in health care systems must first select a “ specific clinical process ” and then accurately specify the value desired by the stakeholders . The process for the PIV5Rights initiative included :
➊ The first step of the LEAN PIV5Rights clearly Defined the goal of 1 PIVC per patient visit .
➋ The second step Measured and determined how many catheters were being used in our hospital every year . PIVC usage for catheter consumption was collected from annualized supply chain purchasing records .
➌ The third step Analyzed and compared the total hospital patient admissions , the number of PIVC purchased annually , divided by the number of patient admissions for the total and average PIVC per patient admission . Nursing labor costs were calculated based on standard work and average registered nurse ( RN ) salary for bedside versus vascular access specialist RN per 20-minute PIVC catheter insertion . The calculation of PIVC supplies used with each insertion established a cost basis for the control arm of average usage supplies and experimental arm with standard work supplies of IV Start Kit , chlorhexidine gluconate ( CHG )/ alcoholic skin antiseptic , 22g 1.75-inch catheter , anti-reflux valve needleless connector , chlorhexidine antimicrobial bordered dressing and ultrasound as needed . Ultrasound cost was not included . The annual PIVC catheter consumption data multiplied by the cost per PIVC placement established the per PIVC catheter insertion economic impact to the hospital .
➍ The experimental arm Implemented the LEAN PIV5Rights bundle approach : ( represented in Figure 1 , Table 1 ) a . Right Proficient Inserter for the least number of attempts b . Right Insertion aseptic technique using visualization c . Right Vein and Catheter Selection with a focus on forearm placement d . Right Supplies and Technologies using an IV Start Kit , CHG / alcohol , 22g 1.75 ” catheter , anti-reflux needleless connector , and antimicrobial bordered dressing . e . Right Management with site assessment performed every 12-24 hours with evaluation checklist and photo accountability through an iPad Cloud enabled HIPPA compliant app .
Click to View the PIV5Rights Bundle
➎ The cohorts were divided into the Control group with current practice procedures and the Experimental group with a centralized specialist team for PIVC insertion process .
The PIV5Rights and the bundle were based on this information : Up to 69 percent of PIVCs fail to reach end of therapy with 1 out of every 2 catheters failing prior to completion of treatment ( Marsh 2017 , Helm 2015 ). Insertion success by clinicians ranges from 12 percent to 26 percent ( Sabri 2013 ). The systemwide hospital review applying the Lean Six Sigma and PDSA approach revealed current practices for PIVC insertion success were 15 percent with pre-study usage of 5.6 catheters per patient visit representing an unnecessary cost waste in nursing labor and supplies . Patients complained of multiple catheter insertion attempts and complications causing failure with a need to reinsert catheters causing a delay in treatment . Peripheral intravenous catheter failure rate at this hospital was more than 50 percent within 24 hours .
The cycle of PDSA is a quality improvement method based on the scientific process where the cycle is engaged to gain information , apply the plan and study the impact . Through the planning stage a problem is identified to improve outcomes or patient care . The Do stage information from staff and records may be collected to reflect current practices and adherence to policies that support or deny the need for the proposed change or an action with the plan is applied . In the Study phase of the cycle the impact of the Do activity is analyzed leading to the Act phase where a decision is made to provide additional support through education or other activities that may lead back to re-initiation of the PDSA cycle .
The PIV5Rights is a PDSA project , Plan , Do , Study , Act processes , that applied the Lean Six Sigma method for improvement , designed to collect data of current practice , analyze the practices and apply evidence-based approach that result in cost savings . Using the information from Lean Six Sigma analysis the team was able to define a standard work process and plan with the PIV5Rights bundle that improved PIVC dwell time and patient satisfaction while lowering complications and costs .
www . healthcarehygienemagazine . com • august 2021
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