Critical care unit improves throughput, works-in progress – and saves lives
By Satya S. Chakravorty
Mindfulness is defined as the "enhanced attention to, and awareness of, current reality or the task on hand." Mindfulness promotes an understanding among individuals of how their actions contribute to improving process performance. It is the ability to hang on to current ideas or concepts, remember them and not allow distractions to obscure them. Mindfulness keeps the mind "steady as a rock" instead of bobbing about like a pumpkin in water.
Steadfastness is a principal characteristic of mindfulness, and combined with a razor-sharp focus on an objective it produces powerful insights and wisdom. Mindfulness practices are most often implemented in three ways:
- Use of frequent meditation
- Willingness to solve problems that are context specific (questioning the conventional "best practice" view – solutions that have worked in one context will work in another context – which practitioners know is not always true)
- Taking the time to meaningfully communicate the current problem or situation to others
The concept of "mindfulness" and mindfulness practices have been implemented in many healthcare operations to improve process performance. For example, a critical care unit (CCU) near Macon, Georgia, an organization that we will call Southern Healthcare, implemented mindfulness techniques to address declining CCU performance. Typically, when intensive and specialized treatment is required, the CCU receives patients from other units, such as the emergency center, the trauma-burn unit and the operating and recovery section.
This CCU is a 20-room facility with rooms at the perimeter and an open central nurses' station for monitoring patient care. The nurses, supervisor and volunteers are located there. Through out the day, nurses return to the station to complete paperwork on patients' medical charts, medication and treatment, and incident reports. The results show that there has been a significant increase in throughput (e.g., number of patients admitted in CCU per year), a decrease in work-in-process (e.g., average number of hours in CCU per patient) and an increase in quality (e.g., live discharge), with a slight decrease in cost. The improvement in the CCU's performance was achieved by systematically applying the mindfulness model.
The mindfulness model was developed using soft systems methodology (SSM), which originated by applying hard systems engineering methods. Many of the basic tools for SSM were developed through a series of real-world projects in unstructured situations.
Over the years, many authors have discussed varying types and steps of SSM, such as Peter Checkland's "Autobiographical Retrospectives: Learning Your Way to ‘Action to Improve' – The Development of Soft Systems Thinking and Soft Systems Methodology," published in 2011 in the International Journal of General Systems. It uses seven stages:
- Confront/identify the problem situation (or event).
- Identify the people, culture or norms involved (i.e., the stakeholders and context).
- Develop root definitions that describe the ideal system.
- Build a conceptual model or a diagram of the system.
- Compare models to the real world and question each relationship in the model.
- Identify changes needed to the current system related to the problem.
- Take action or use an action plan to implement the changes previously identified.
Mindfulness greatly improved the application of SSM stages one, two and six by encouraging a high level of attention to a task (or awareness of it) and an understanding of how the players contribute to improving process performance or customer service. The first step of mindfulness – frequent meditation – avoids distractions, focusing attention on the immediate threat to a patient, a problem or its causes (SSM, stage one). The second step emphasizes objectively examining the context and stakeholders (SSM, stage two), and develops effective or appropriate solutions that are context specific (SSM, stage six). Instead of relying on a "best practices" view, the objective examination promotes datadriven analysis of a situation to discover and implement the best solution.
At Southern Healthcare, doctors, nurses and volunteers are encouraged to meditate five to 10 minutes every few hours and then clear their mind for one to two minutes before treating each patient. To keep superficial reactions from becoming an issue, caregivers are taught the third step of mindfulness, which is to communicate often with other caregivers about patient condition, and briefly evaluate how a treatment affects each patient. The mindfulness model in Figure 1 shows the relationship of SSM and mindfulness techniques.
Southern Healthcare developed a meticulous implementation plan that showed current and future targets, delineated milestones of achievements and showed action plans for implementing the mindfulness model. Specifically, the plan consisted of a sequence of task dependencies, which included welldefined predecessors and successors and clearly identified routing information to complete the implementation. The following describes implementation activities for each aspect of the mindfulness model.
Confronting/identifying the problem (stage one). To identify process failures, the CCU needed to be preoccupied with failures. The CCU focused its attention on identifying reliability of activities or consistency of performance. For example, before the implementation, the CCU measured reliability as the "percentage of patients discharged alive." Since CCU performance was focused on the death of patients, intermediate mistakes often were not considered critical as long as they were recoverable. The caregivers realized that many successes depended on these intermediate mistakes. As a result, the caregivers developed two intermediate dimensions: the activities related to discharging patients alive; and steady vital signs (e.g., physical indicators, such as blood pressure, temperature and oxygen level, and psychological indicators, such as anxiety and alertness).
As part of an implementation, the CCU tracked activities related to these intermediate dimensions. At this point, preoccupation with failures that influenced the CCU's performance became the focal point. Caregivers were asked to meditate for 10 minutes and focus on potential failure points or breakdowns. They identified six significant factors that undercut the CCU's reliability: unqualified caregivers, faulty equipment, poor nurse-doctor understanding on treatment, slow nurse response time, incorrect patient admissions and unit cleanliness.
The caregivers documented multiple activities related to the six factors contributing to the CCU's failure or declining performance. They were discouraged from establishing cause-effect relationships or assigning blame to employees and encouraged to maintain objectivity and consider behavior, not perceived intentions or motivations.
At the beginning of each shift, CCU conducted informal inspections to ensure that the unit complied with the minimum standards. One item of inspection was accuracy and timeliness of treatment. In other words, medication administered to the patients would maintain effective nurse-doctor understanding of treatment. Another item was unit cleanliness, where failures could lead to infections for the patients. Every day, items that appeared on inspection reports as failure points were discussed at the staff meetings, and corrective actions were immediately taken. The inspection report encouraged the culture of "preoccupation with failure" by listing the activities that could degrade the CCU's performance. The inspection report also included successful points. Significant differences in points were flagged for immediate corrective actions.
Identify the people, culture and norms involved (stage two). The next step is to develop an understanding of the system, which includes people (or process owners), culture and norms (or standards) of practice. This links system inputs and outputs to determine relevant variables that are controllable, along with their interaction with the CCU's performance.
Two examples are the rates of "live discharges" and "stable vital signs." To enhance CCU's reliability, there should be a reluctance or unwillingness to oversimplify. Instead, there should be a willingness to discover distinct relationships that are specific to the situation. This line of logic questions the assumptions that are tied to solutions and discourages the adoption of best practices that have worked in different situations. Putting it differently, oversimplification of causeand- effect relationships, or suggestions for use of off-the-shelf best practices to determine failure points, produce ineffective solutions that deteriorate performance.
It is important to fully understand the existing process (including people, culture and norms) and how a change in the process affects the unit's performance. Many norms affect the CCU's reliability. Particularly, the diverse environment and culture created challenges that diminished the unit's response time. For example, in Muslim cultures male doctors are not allowed to perform physical examinations of female patients. Unfortunately, these patients must wait until a female doctor becomes available. In another example in a different context, over time, the contingent of patients who speak only Spanish has increased, but the number of Spanishspeaking caregivers has decreased.
Stage two of the mindfulness model addresses these cultural considerations. Mindfulness encourages doctors and nurses to take one- or two-minute breaks and clear all matters not related to the patient from their minds. Doing so gives undivided attention to the immediate problem and its unique characteristics, thus avoiding a swift administration of a treatment.
Police hope mindfulness will cut stress and violence
Mindfulness is slowly gaining inroads into the business world – and the world of law enforcement.
Quartz Media has reported that the Dallas police department turned to mindfulness to reduce stress after a U.S. army veteran killed five police officers last year. A philanthropist provided the financial backing for 500 officers to receive mindfulness and cognitive training. The technique aims to change how officers manage stress and emotions, emphasizing a deliberate, thoughtful response as opposed to a rash reaction. The aims are to help officers cope with trauma and violence. Other departments, including Seattle and Madison, Wisconsin, are implementing mindfulness programs to deal with what researchers say is one of the highest levels of stress in all occupations.
Developing root definitions that describe the ideal system (stage three). After understanding the context, the next step is to clearly define CATWOE – customer, actors, transformation, worldview, owner and environment – and then articulate the CCU's ideal state. The ideal state may not be immediately possible, but that should not discourage you from succinctly stating the future state to discourage reluctance or unwillingness to simplify. Customers benefit from the CCU's reliability, but we should remember the larger issue of societal benefit and the benefit of preserving life. "Actors" are all of the participants involved in transforming inputs into outputs that influence CCU performance. The transformation process defines exactly what and how inputs are transformed into outputs. The "worldview" ensures any improvement in performance or reliability contributes to society by preserving life, the foundation of modern civilization. The "owner" has the lawful authority and responsibility for managing resources and outcomes. The "environment" sets the boundaries of the solution based on the context.
A clear understanding of these variables provides the details for the current and ideal condition of CATWOE, which is similar to the current state and future state diagrams found in lean literature. Root definitions, or the ideal CCU system, can be summarized with six brief statements.
First, the customers in the CCU are the patients whose lives were saved. Medical malpractice claims cost an enormous amount of money, therefore, improving the CCU's reliability significantly reduces overall societal costs. To Southern Healthcare and insurance companies, the ideal condition is to prevent malpractice claims.
Second, the actors are the participants, doctors, nurses and volunteers responsible for improving the unit's performance or reliability. The ideal condition for actors is to improve reliability by providing faster response to patients' treatment needs.
Third, the transformation process is reflected in the CCU's performance measures. The inputs are critically ill patients with unstable vital signs and their caregivers. The outputs are "transformed" patients who leave the unit alive and with stable vital signs. And note that success in transformations curtails medical malpractice claims.
Fourth, in the worldview, an increase in the unit's reliability increases the preservation of life, which cuts medical costs. Reduced medical costs free cash to improve other departments and provide greater benefits to the owners.
Fifth, the owner determines who controls and assumes liability for the CCU. The Southern Healthcare president and the insurance companies are responsible for poor reliability.
Sixth, the environmental constraints create CCU's conditions that limit reliability.
For example, the CCU can't choose patients, and at times, some patients are admitted who are not appropriate for the CCU. Patients who are too sick should be admitted to the intensive care unit (ICU). Patients who are too healthy should be admitted to the general care unit.
Events that generate these constraints are difficult, if not impossible, for the process owners and actors to control. A root definition is like a mission statement that includes all objectives. Specifically, the ideal condition for the CCU is, "Actors improve reliability to 100 percent so that all patient lives are preserved, resulting in societal gain and no malpractice payouts."
Building a conceptual model (stage four) and comparing models to the real world (stage five). Conceptual models create a visual representation or a diagram of the system, which enhances our understanding of how individual parts work together to create a system of complex processes. After the models are built, the process owners can evaluate how well the models represent the real-world processes. Conceptual models of CCU activities show causal links and generate consensus among the actors in pinpointing variables that impact reliability. Figure 2 shows the conceptual model of CCU activities or variables that impact reliability. The figure displays the transformational process, connects inputs to outcomes and allows sensitivity analysis, where impact of a change in one activity can be studied to determine its effects on others.
For instance, the CCU admits patients from other units, such as the ICU. After the CCU completes caring for them, patients are released. CCU performance affects other units of Southern Healthcare and often involves different actor interactions. In other words, units that receive patients from the CCU could affect reliability. To implement sensitivity to operations, physicians and nurses from other units were encouraged to provide feedback or share their experience with CCU personnel in face-toface conversations to better promote effective communication.
Identifying changes needed to the current system (stage six). This stage focuses on identifying solutions to the problems that degrade reliability. Both problems and solutions must be measurable; otherwise there will be no improvement. Any meaningful change that addresses the problems should improve reliability.
Mindfulness was particularly helpful in guiding caregivers to meditate on a specific problem and conceptualize possible solutions. In medical practices, a "best practices" approach does not always apply because of the high variance in patients' severity of illness or injury, age, gender, mental state or attitude. To facilitate mindfulness, an unused break room with comfortable furniture and little noise was designated. Immediately following a break, caregivers diligently documented their change ideas or solutions for subsequent discussion. Emphasis was on identifying changes throughout the unit, especially at front-line levels, which can be very effective in recognizing problems early. The frontline caregivers can quickly recognize threats and implement solutions to address or prevent such threats.
Mindfulness supports identifying feasible and desirable changes to counter immediate threats at the lowest level of the organization. Instead of a hierarchical structure, where decision-making is driven from the top, mindfulness promotes a relatively flat organizational structure, driving decision-making from the bottom based on the expertise of the process owners.
At Southern Healthcare, the CCU's organizational structure is relatively flat. Nurse supervisors control manpower and assignments, and physicians or doctors control treatment. Nurses occupy the next level and are responsible for providing care. CCU nurses execute a doctor's treatment procedure. The majority of the requests to change (or adjust) treatment are generated by a lower level nurse, not by the doctors. Before recommending changes, however, nurses were encouraged to meditate on the problem and discuss their changes with peers before suggesting them to a doctor. While maintaining a flat organizational structure, one limiting factor has been the insurance providers and managed-care structures, which follow a hierarchical makeup.
Taking action or developing an action plan to implement changes (stage seven). The CCU encourages implementing a solution if the solution is simple or developing an action plan if the solution is complex. To develop solutions, the CCU relies on front-line experts. Studies demonstrate that solutions developed and implemented by the lowest practical level of the organization are very effective in improving reliability.
Organizations with high reliability commit to resilience and activate resources to maintain the reliability. Resilience was implemented through action plans, which included a protocol, or list of specific activities to be executed in the event of a process failure. In the CCU, following the protocol resulted in speedy recoveries from failure. Resilience was very much a part of the CCU's action plans.
For example, the unit has many lifesupport devices, which can trigger an alarm and activate life-saving procedures when patients are threatened. The CCU and the ICU shared equipment; however, the ICU was considered a higher priority. As a result, equipment was minimally available to the CCU. An action plan called "critical locator" was developed, which could be initiated by any nurse or doctor. Initially, wireless tracking devices were used to locate the necessary equipment. If available, the equipment was rushed to the CCU. Fast and accurate communication of information promotes resilience and facilitates organizational reliability.
Saving lives and learning lessons
Figure 3 provides the results of the implementation in three broad categories: efficiency, process and outcomes.
Efficiency includes the cost and time of patient care. After implementation, the costs of patient care decreased by $100 per patient, reversing a trend of increasing costs. These improvements were achieved in fewer hours (70 vs. 73) necessary for patient care for a successful discharge. Process measures reliability in terms of percentage of patients discharged alive with stable vital signs. Before the implementation, reliability was 93.8 percent. Following the implementation, reliability increased to 99.5 percent. Outcomes such as mortality rate of acute myocardial interaction (AMI) and the percentage of patients discharged alive are both reliability measures. The results show that fewer patients died from AMI, 1.5 percent before implementation, down to 0.9 percent after implementation. The percentage of patients discharged alive improved 100 percent, going from 22 deaths per 1,997 admissions to 22 deaths per 4,020 admissions.
Two lessons stand out from implementing mindfulness to improve process performance. The first lesson is that there is a propensity to embrace popular best practices or improvement programs without success. It is important to understand that, despite heavy promotion, many improvement programs fail. One reason for the failures is that improvement decisions often are driven from the top instead of by front-line employees who best understand the process.
Studies clearly point out that significant improvements do not take place until improvement decisions are driven from the bottom. In fact, one of the physicians admitted that "during heavy demand periods, standard treatments are sometimes applied without due consideration to the patient … due to the desire to relieve immediate suffering at all costs, even when alternative treatments may be more effective long term."
The second lesson is that mindfulness encourages front-line employees to make improvement decisions and drive improvement programs from the bottom. Mindfulness encourages reflection on problems that are context-specific to deliver improved patient care through unique, targeted treatments. Healthcare providers are no longer compensated for mistakes made by their institutions. As these costs run into the millions of dollars per incidents, the benefits of applying mindfulness may have huge impacts.
Satya S. Chakravorty is Caraustar Professor of Operations Management at Kennesaw State University. His Ph.D. in production and operations management is from the University of Georgia. He is a certified fellow in production and inventory management, a Jonah in theory of constraints and has a lean Six Sigma master black belt. His research has been published in journals that include MIT Sloan Management Review, The Wall Street Journal, APICS Magazine, Quality Progress and Industrial Engineer.
This article was written by Satya S. Chakravorty and was originally published in the September issue of ISE Magazine.