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Roxanna Gapstur: On this episode of Inspiring Health, we're putting real-time problem solving under the microscope. We're going to take a closer look at how we're applying RTPS to find solutions that will improve patient safety. We want to improve our delivery of highly reliable care.

Joining me today is Renee Saylor, Assistant Nurse Manager of the B1 Med/Surg Unit at WellSpan Gettysburg Hospital. Renee began her nursing career in the Critical Care Unit at Waynesboro. She later transitioned to WellSpan Chambersburg Hospital, where she spent a total of 16 years. In Chambersburg, she provided direct patient care in the critical care and progressive care units later earning a leadership role as a clinical manager.

Today, Renee is responsible for leading a large team of nurses, nursing attendants, and unit secretaries who provide direct care to surgical, orthopedics and oncology patients at WellSpan Gettysburg Hospital.

Renee, thank you so much for being with us today.

Renee Saylor: It's my pleasure to be here. And honestly, problem-solving is kind of a passion area for me. And I also love teaching, so being able to combine these two and having the opportunity to coach my team to solve patient care issues has been a high point for me.

Roxanna Gapstur: Oh, that's great, Renee. As you know, we're still in the early phases of implementing our Lean management system at WellSpan, but real-time problem solving is a key component of that system. It should empower all 20,000 team members to improve their own work processes and take an active role in understanding the root cause of an issue. Can you remind us what real-time problem solving is and how it differs from standard root cause analysis applications?

Renee Saylor: Absolutely. When a problem occurs, performing a root cause analysis helps to identify the issue and develop a solution so work can continue. But we have all experienced times when the problem occurs again and again, and we realize we didn't ask the right questions or investigate the issue thoroughly. Real-time problem solving is a systematic approach that helps team members develop a methodology to truly understand the cause of a problem, fix it for good and share it with others across the system.

For better understanding, I need to share this analogy. Probably like many people, growing up, I was influenced by music and movies. So when I think about real-time problem solving, it's kind of like being in a classic movie from the 1980s. You know, where there's always a challenge presented that needs to be overcome. And when it seems like the characters can't go any further, they launch into this montage and put in the work to overcome the challenge. So real-time problem solving is the montage just without that catchy song. But honestly, Roxanna, if I could find a way to get my team to break into song while applying real-time problem solving, I would be absolutely delighted.

But back to the main point, since most problems are more complex in nature, we need to take a multifaceted approach to identify what is truly causing the issue and develop a countermeasure in as close to real-time as possible.

Roxanna Gapstur: Renee, that is a funny analogy. I'm not a good singer, so I'm not going to break into song, but I think that's a really unique way to look at how real-time problem solving works. I mean, let's take a look at an issue that you and your med/surg team at WellSpan Gettysburg have encountered. And just walk us through the montage of how you used RTPS to get to the heart of the issue, and then developed a solution to prevent it from recurring again.

Renee Saylor: Absolutely. So we had a patient who needed a specific medication order entered for their treatment plan. The medication was not one that was routinely administered in an acute care setting, and the staff were unfamiliar administering the medication and the monitoring requirements. In this case, the nurse and the pharmacist worked together using Micromedex and identified a TB test is required to rule out tuberculosis before the medication has to be administered.

The physician was contacted to order a TB test. However, Micromedex had identified several testing variations and does not have a set process or protocol. It was determined that the PPD test was used to rule out TB, but it has a 48- to 72-hour delay before results could even be obtained. And the medication was administered after the PPD test was started, but prior to the window for the results to come through. The patient had previously received this medication and may have previously been tested to rule out TB. But at the time the medication was administered, the care team did not have knowledge or documentation of the patient's prior testing or medication history.

Roxanna Gapstur: Well, fortunately this scenario did not result in any harm to the patient, but your team recognized the potential for a patient safety event and they initiated real-time problem solving to identify the cause. And they then set up a protocol to prevent this from happening in the future. I mean, as you mentioned earlier, Renee, the root cause of this problem is complex and numerous factors needed to be identified to isolate and counteract the issue. Tell us more about the steps that you took and how you use the Four C tool to solve the problem.

Renee Saylor: The Four C tool was key to solving this issue. The Four C tool is a simple table designed to prompt inquiry and conversation. The Four C's stand for concern, cause, countermeasure and check. And using a team approach, we work our way through the table to get an outcome that will prevent the problem from reoccurring.

In this case, we identified the concern as the medication being ordered without identifying the parameters for the TB testing requirement. The nursing pharmacists were unfamiliar with the process for administering the medication. Micromedex specifies that TB test needs to be obtained and TB ruled out before initiating the medication, but there was lack of knowing which TB test is to be used.

We move to the cause box next, which is the most crucial difference between simple root cause analysis and successful real-time problem solving. When determining the cause, you use the five-why rule to ask why five times to peel back the complex layers of the problem and identify the true cause. So asking why is what's key to the Four C. Even if you don't have children, most people have at least observed the interaction between a parent and child when the child persistently asks why. And the parent tries to give the answer, but after the hundredth why, the parent responds with "Because I said so."

Roxanna Gapstur: Renee, I think if you made it to a hundred why's, you have a lot more patience than I do.

Renee Saylor: Oh, well, Roxanna, having children and learning patience certainly gives preparation for real-time problem-solving. Now, maybe the child keeps asking why because they like the interaction, but maybe it's because they're having a difficult time communicating what they don't understand about a situation or they lose focus on what they really wanted answered or solved. So for this reason, it's crucial for leaders to help guide the why questions to identify the actual root cause. Otherwise, the countermeasures or fixes you apply to permanently address each root cause is not going to prevent the problem from occurring in the future. For this specific case, the communication between the physician, nurse and pharmacist was suboptimal. When initially asking why, the nurse quickly identified the issue of how healthcare workers shortages are impacting all involved, as well as time constraints, making it challenging to identify the parameters for the order.

Now, if we stuck with the healthcare worker shortage as a focal point and kept asking why specific to that, we would go down a rabbit hole of how to get more staff on board. But honestly, if somehow tomorrow magically all healthcare workers were in surplus and this medication was ordered again, the same problem would present because the root cause is not staffing, it is suboptimal communication.

By directing the why's to the communication issue, we identified the current order set did not have a hard stop when ordering this medication

from there, we moved on to the countermeasure section to determine and test solutions to address every root cause. First, we identified a proper process and testing requirements for this medication, but then we needed to specify within the medication order all necessary additional testing to ensure all requirements are ordered and communicated for medication administration. This included developing an order set with hard stops and we needed to provide education to all staff on the new process.

Roxanna Gapstur: Wow, Renee, this is a great example of how complex systems can still have holes in certain functions. And when they occasionally line up, the improbable can occur. Your team did an amazing job of identifying the various root causes and developing countermeasures. But there is one C left on the Four C tool. How did you check to validate the countermeasures were put into place and that they were functioning properly?

Renee Saylor: Well, we documented the action items that were taken to check that they were in place. It's extremely important to understand the health chain and knowing the difference between the need to escalate a problem to share awareness in the system, versus when you're escalating because you need help with the problem. In this situation, I was appreciative of our tier 3 huddle, because it was the perfect place to escalate it, that I wasn't sure who was the next person in the help chain for me to go to get help with to solve for that last countermeasure and performing the check section of the Four C.

Thankfully, with our diverse leadership and daily attendance, it was a leader from the outpatient infusion center and our informatics specialist who jumped in to collaborate in the effort. Our collaborative team consisted of a frontline RN, the pharmacist, managers from inpatient and outpatient settings, our informatics specialists, Epic optimization team and even our chief medical officer.

We reviewed Micromedex for the indications for this medication, worked together to identify what communication was needed, the most efficient way to communicate the information and develop the parameters and hard stops in the order sets to submit to the electronic health record administrator to update. In total, it took four days for our team to work through all the steps of the real-time problem solving process and create a solution.

Roxanna Gapstur: Renee, I go back to your analogy of real-time problem solving in that '80s movie montage. It's amazing what you and your team accomplished in four days by using RTPS and the Four C tool. It's really a shining example of how Lean tools can help WellSpan on our journey to become more highly reliable, and also shows that every team member has the ability to identify problems which could improve our protocols or the care we provide to patients.

Well, this example addressed a clinical problem. Your team also utilized RTPS on another concern that really demonstrates how every team member can engage in identifying causes and solving them. Can you share more about the challenge with patient trays?

Renee Saylor: Yes, Roxanna. This is a good example of how real-time problem solving can be applied to any issue or concern. We used the Four C tool again. And in this instance, the concern was that a meal tray was delivered to the wrong patient in an isolation room. We asked the five-why questions to determine the cause, which was that the team member did not use two patient identification when delivering the tray. This was due to nursing and the ancillary team members assisting with tray delivery, trying to bundle care in COVID patient rooms and the patient acuity and workload was prohibiting full concentration on nonclinical tasks. We also discovered that the team members involved did not know to use two patient identifiers since they were not accustomed to delivering meal trays and were floating from other areas. Typically, nurses use the two patient identifiers whenever they're passing medications. So it didn't even dawn on them that they should be using that also with meal trays. Compounding the problem was that the patient label on the tray is hard to read. Eye protection needed to be worn in isolation area, which after being reused and cleaned multiple times can create a fuzzy view of the small print on the label.

The team developed countermeasures that included investigating if the print on the patient label could be made larger or easier to read and reminding all team members to make a purposeful pause before each action. Additionally, we realized there was an educational opportunity to advocate for all team members to understand the patient safety aspect of delivering meal trays to the correct patient.

Roxanna Gapstur: With the surge of COVID-19 patients and the demands heightened in certain clinical areas, more team members are lending a hand in departments or in roles they don't normally perform. It's easy to see how they could find themselves in a similar situation. So fortunately, we've got a great tool in RTPS, which every team member can put into practice.

Renee, I want to thank you again for joining me today and sharing these examples. In fact, shared learning is another key component of WellSpan's Lean management system. And your being here today to spread key learnings will benefit team members and patients across WellSpan. There's much to be learned from one another as we pursue providing the safest, highest quality care and best experiences to our friends and neighbors in South Central Pennsylvania.

Thanks so much, Renee, for being here.

Renee Saylor: Oh, thank you. Roxanna. It's certainly was a pleasure to be here with you today.

Roxanna Gapstur: That's all the time we have for today. We hope you'll join us for the next episode of Inspiring Health.