Using A3 Thinking to Address Safety Issues in the ED

Abstract

Session J presented Saturday, September 29, 11:30 am-12:30 pm Purpose: The health system has a stated vision “to create 15,000 problem solvers” through implementation of a lean daily management system, including process improvement tools to address safety issues. Baseline Culture of Safety survey data of Emergency Department (ED) staff also indicate opportunity to improve overall perception of safety and provide education on error prevention. The objective of this evidence based practice (EBP) quality improvement project was to educate ED staff on utilization of the A3 tool to identify and address safety concerns in the ED and improve overall perception of safety. Design: The Johns Hopkins Nursing EBP Model was used and literature review performed using databases Medline and PubMed, with key words “Lean; Lean thinking, interventions, safety interventions; quality improvement; A3.” Seventeen articles reviewed, nine were good quality to support the EBP quality improvement project. Literature defines LEAN as operating philosophies and methods to create maximum value by reducing waste and waits. LEAN culture views problems as opportunities to improve processes. LEAN problem-solving steps are: identifying the problem, understanding current state, developing ideal state, performing a root cause analysis, determining countermeasures, creating an implementation plan, and checking results to confirm effect. Setting: 141-bed community hospital ED (approximately 30,000 annual visits), in south central Pennsylvania. Participants/Subjects: All ED staff participated. Methods: Experienced ED RN’s rapidly use the nursing process: assessment, diagnoses, planning, implementing and evaluating, to provide safe patient care. Nurses are trained clinical problem solvers. Lives depend on their skills. When nurses are faced with process-related problems, they problem solve, using tools from their training. Process problem-solving requires a more structured, continuous improvement approach closely resembling the nursing process. A3 problem solving, first employed at Toyota, is based on principles of Plan-Do-Check-Act (PDCA), the manufacturing version of the nursing process. To engage nursing in this problem-solving process, ED staff was educated on LEAN methodology and the A3 tool. Daily safety huddles were conducted where exposure and education to A3 thinking was introduced and role-modeled. Opportunities to improve safety were identified by front-line staff, A3 thinking applied, and standard work developed. Opportunities identified ranged from immediate safety issues to everyday process problems which were barriers to providing safe care. To measure success, the number of A3’s in progress throughout the ED, including those led by front-line staff were tracked. Additionally, the AHRQ Culture of Safety survey was administered to the ED as part of the annual employee engagement assessment. Results/Outcomes: AHRQ Culture of Safety ED survey results from 2016 to 2017 indicate a 12.8% improvement in rating of overall perception of patient safety, and 19.1% improvement in procedures and systems are good at preventing errors. In addition, 4 group A3’s have been completed in the ED to address safety issues, and 2 additional A3’s are in progress being led by front line staff. Implications: LEAN activities increase safety awareness among front-line staff and overall perception of safety culture. Evidence suggests utilizing lean interventions, including A3 thinking, promotes staff engagement in identifying and solving process problems, and developing standard work to sustain process changes to improve patient safety.