Over the last 8 years, NorthCrest Medical Center, a 109-bed, nonprofit community hospital near Nashville, Tennessee, has become as nimble as it is structured. Under CEO Scott Raynes, NorthCrest embraced Lean and uses “CUSP as a way to become more Lean.” At the same time, “nothing that we are trying to improve doesn't have a CUSP team,” according to Randy Davis, his CIO and Senior Vice President for Performance Improvement.
Organizational and Cultural Context
When NorthCrest's 8-year contract with HCA ended early in 2005, Raynes was recruited to be President and CEO. The medical staff had no organization or structured process within which to discuss and vet evidence-based practice or improvement initiatives, or to function as a department. Within 18–24 months, Raynes had identified a new senior team, organized medical departments with elected chairs and vice-chairs, and had begun realigning the organization around the “five pillars of excellence” (people, service, quality, financial, growth) extolled by the Baptist Leadership Institute. Resistance of clinicians who were more comfortable with the old “wild West” style was overcome by the “selection of key folks who had great clinical knowledge, were passionate about patient-centered care, stubborn enough to fight the good fight, knew it was a marathon and not a sprint, and believe perfection is our goal,” said Raynes. “That's where Lean came in, and zero defects.”
As the organization continued to evolve, the development of thoroughly defined goals, action plans and metrics cascaded from one level to the next, creating shared understanding and alignment. Davis, the last of Raynes' senior team to join NorthCrest in 2008, elaborated:
“We believe success is achieved through good communication and explaining the rationale behind what we are doing. I should be able to sit in the boardroom and hear the message, and go down to the cafeteria and hear the cashier describe her piece of it and how she is getting there. We take the pulse of the knowledge of people on the floor, have little daily huddles, and help them with elevator speeches so they can describe what the hospital is trying to do and their own role in it.”
Angie Beard, R.N., M.S.N., Chief Nursing Officer, and Vice President of Professional Services, depicted Raynes' leadership style and the motivating impact of working in an aligned organization:
“That's why I come to work every day. Everyone knows what our organizational goals are and gets the same reports. The same messages and data—about falls, hand washing or patient satisfaction—are posted on every bulletin board. I'm a Southern girl, and we say that you can't lead a team of horses by pulling them. But if you stand behind and drive them, they can take you anywhere. That's how Mr. Raynes leads—by steering, not pulling.”
Once Raynes had a senior team in place and restructuring for alignment and accountability was in process, he turned outward to successful quality and safety initiatives. How to bring them home and build them into NorthCrest's culture and metrics? Being only 30 minutes from Nashville and its choice of hospitals, he was acutely aware that “we have to measure up and differentiate through clinical excellence.”
Raynes worked with the board Chair to put a conversation about quality in front of the board by forming a Quality Review Committee (QRC) composed of senior administrators, physician leaders and board members—including its Chair and the Chair of its Quality Subcommittee. By monitoring and keeping quality and safety initiatives in front of key organizational stakeholders through this board committee, he also furthered his objectives of transparency and accountability.
Learning from Defects became an occasion for educating and improving. After near-misses and adverse events, all people affected were brought together to conduct a root cause analysis. The scope of such inquiry has now broadened to situations where there could have been a serious mistake. Root cause analyses are conducted to change processes to prevent future harm. Beard elaborated: “We want to be in front of the fire, not behind it. The biggest question I ask staff is: ‘How will we harm the next patient?' The staff always knows the answer. They know where our weak spots are.”
One of those weak spots, the nurses pointed out, was the lack of a pharmacist on site at night to check an order against known patient allergies or interactions with another drug. Now, an off-site pharmacy that is part of the same company as NorthCrest's pharmacy reviews night orders before a nurse gives a dose.
The nursing administration began to take compliance for the central line bundle and the ventilator bundle to the QRC and then to the board during 2008 and 2009. It was necessary for nurses to be empowered to stop a procedure when, for example, a sterile field was broken, a physician was not in full compliance with a standard, or for any patient safety issue. Nurses also had to know that they would be supported. Beard, who had been Chief Nursing Officer (CNO) for the past 3 of her 25 years at NorthCrest, described this moment:
“Our board is very involved; they are responsible for governance and quality of care. The biggest question was: what will you do with noncompliant doctors? It was a huge step for the board when they said that if physicians don't comply, they cannot work here. This was an enormous cultural change. If a nurse stood up, she knew the board would support her. What stopped most of the noncompliance was the understanding that they would get in trouble if they didn't stop the procedure. The second thing was peer pressure among physicians.”
Raynes described the change:
“It was a huge shift for nurses knowing they would be backed up. It really pushed the patient to the center of care. We had doctors who had done as they pleased, there had been no standardization, and the nurses had had to meet and work with each of them. Once we were structured and had narrowed the variation, then we could start to empower nurses to acknowledge outlying behaviors and care practices. That transition was huge.”
With the possibility of suspension of privileges in the background, conversations usually produced the desired result, as Raynes elaborated:
“Adherence to bundles is addressed by the QRC and escalated, if need be, to the board, and into each department. If you have a physician not adhering to a bundle, the Chair of the medical staff will engage with them and work to change behavior. They have a window before it escalates to a higher level that can lead to suspending privileges. Normally, once you get someone's attention, they change their behavior.”
The cultural shift of supporting nurses who brought forward safety extended to nurse-nurse relationships as well. To enhance care while not disrupting camaraderie among nurses leadership created an environment in which making recommendations does not single people out. A box for recommendations was set up, and the administration responded to these recommendations. Raynes sent an email to the entire workforce asking for ideas to enhance safety and quality. Ideas were vetted by senior administration, and Raynes replied individually to the individuals who suggested them. Raynes found that staff had begun to trust that, “it really is about patients being safer. Everything is an opportunity to educate and improve.” Those opportunities increasingly arose and were addressed in real time. Raynes said, “Care encounters are fluid, and, thus, so are the opportunities to improve care. Because of our unit structure and having become so Lean, we are able to nimbly address issues as they arise. We are at a size that allows us to operate this way, but we think it's scalable.”
Integrating CUSP With Another Improvement System
Quality conversations were taking place at every level, and with staff becoming versed in root cause analysis, the stage was set for Lean and CUSP, both pushed by Raynes.
“I set a target of zero with CLABSI, VAP, falls and every other measure that we know is important to patient safety and readmission rates. Everyone from me to unit managers has goals and metrics around safety and quality, so it was easy to establish CUSP teams to plug into what we had already done. We view CUSP as being clinical outcomes, and we deploy it through Lean.”
As staff worked on their root cause analyses of adverse events and near-misses, they realized that many of these events were the products of broken processes that had never been examined. Nursing leaders asked Davis to sit in on their root cause analysis work and take them through a Lean value stream mapping process. As NorthCrest's process improvement needs became evident, Davis invested in further Lean training and sent four high performing, non-managerial staff to extensive Lean training at a local university so they could serve as Lean guides and facilitators, each serving a set of departments.
Bringing both Lean and CUSP into the organization initially struck some clinicians as too much. Beard said, “We had to show them that you can use Lean for the CUSP team.” Asked how the two complement rather than overwhelm, she said, “We use CUSP to tear a problem down, then Lean it up to rebuild it.”
In 2011, NorthCrest revitalized its CUSP work. Raynes put Beard and Davis in charge of CUSP as its senior sponsors, and they set up a new process for setting up teams. Anyone could suggest a CUSP team when they saw an opportunity affecting patient safety. If the senior leadership team agreed, they assigned Davis or Beard to go to the medical department most directly affected, and try to engage a physician to work with the team. Teams had to be multidisciplinary yet small enough to be effective. Each team developed its scope, goals, plans, metrics, and end point and made quarterly reports to the QRC. The first 15 minutes of every monthly QRC meeting is a rotating schedule of CUSP teams.
In early 2012, CUSP teams took off following a state-wide quality improvement collaborative meeting at a local hotel. A group of NorthCrest staff were able to attend that day; besides Davis, Beard, and other nursing leaders, attendees included administrative assistants, a physician, staff nurses, a pharmacist, the quality nurses and a lab technician. As Davis recalled, “a lot of people went and came back almost as if we had been to a revival. It wasn't as much the meeting itself, but having all these conversations during breaks and lunch outside the hospital setting.”
Davis acknowledged that, at first, senior leadership had allowed managers to be team leaders (partly because of their more polished presentation skills) and that the results were “awful.” They learned that CUSP team leaders need to be front line people who are peers of the other members, and that a peer review was needed every 2 weeks. “They cannot come in with the same status as last time; they have to show progress. Suddenly, the CUSP teams took on a life of their own, coming up with solutions we never would have thought of.” Senior staff also learned that team leaders and members need coaching to communicate more effectively with medical staff and people who are not on their team but are impacted by their work. Training is provided by senior-level sponsors.
CUSP teams are set up to have a finite life cycle. Davis said, “We want teams to see light at the end of the tunnel. They need to know when they are done.” Alternatively, a team may achieve its original goal, and then develop more aggressive ones and evolve new teams to deal with them. When NorthCrest reached and stayed at zero with CLABSI, team members began asking themselves: Why are we using this many central lines? Are they all really necessary? How can we reduce the number of line days? They developed guidelines about when it is appropriate to use central lines, monitored daily use, and removed lines earlier. They set a goal of reducing central line days by 25 percent by 2013.
When they investigated why central lines had been inserted in the first place, they were surprised to find how often it was for staff convenience. Beard said, “IV access is not a criterion for a central line.” They created an algorithm for when a central line is necessary and trained people to use it. Their next round of questioning: Is all that blood work at the lab really necessary?
The CAUTI team had a similar experience. The Med-Surg unit got very good at removing the indwelling urinary catheter within 2 days post-operatively and getting infections close to zero. Sometimes they would notice a urinary catheter had been put back in a few days later. No urinary tract infection (UTI) developed, so the device was sterile, but why put it back in at all? Was it because it was easier for staff than using bedpans or getting patients to the bathroom? Had bladder scanners been used correctly? Was the patient actually retaining urine? Davis noted, “Nurses drive physician practice. If they suggest a urinary catheter, the doctor will probably go along with it. If instead they say they are willing to check the scanner and think they can keep it out, the doctor will probably go along with that, too.” NorthCrest no longer stocks indwelling catheters in the Emergency Department. Once a catheter is removed, the staff makes sure another one is not put in except when clinically indicated in special circumstances.
Davis highlighted the common foundation of Lean and CUSP. Both “empower employees to continually improve processes” and thus shift management's role to “clearing roadblocks and hurdles.” And at NorthCrest, Lean and CUSP both “focus on the patient-centered workflow rather than a specific location or unit in the hospital.” The “unit” around which multidisciplinary CUSP teams are formed is not the CCU or Med-Surg, but the “work unit”—the people who interact on their shift to get their work done: nurses, pharmacy, pulmonary care technicians, environmental services, radiologists, and hospitalists. “There is no difference between how we organize our CUSP teams and the Lean process of following the workflow.” Beard made a similar point and drew out the implications for silos. “CUSP is helping to break down silos by putting the patient rather than the department in the center of the organization. The best practice standardization of care that CUSP advocates also works to break down silos.”
Raynes summarized how he saw the Lean-CUSP relationship:
“We have embraced and embedded Lean in all aspects of our organization. We are always looking at what we can eliminate because it brings no value. Lean is built into every thought we have. CUSP is a method that fits like a glove. It is a way to become more Lean. Now we have eliminated this infection; what's next? We can get rid of all those line days that are unnecessary. We are never not asking why.”
For more information about NorthCrest, visit their website at www.northcrest.com.