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2017 Annual Report: Problem Solving with OpEx

Focus on Improving Safety, Quality & Patient Experience

Kathleen “Kat” Hastings, RN, IBCLC, has witnessed the joy of parents welcoming a newborn into their family, and the tragedy of parents losing an infant to SIDS or a sleep-related cause. As nurse manager of Women and Infants at Pen Bay Medical Center (PBMC) Birth Center, where she has worked for more than 20 years, Hastings has participated in some way in the birth of more than 1,000 babies.

So when she and her nursing team were noticing a pattern of inconsistent comments or questions from expectant or new parents about infant safe sleep and swaddling — info parents had heard, researched online or read in a magazine — the team decided to take action. “The info they shared with us raised a red flag, so we decided we could use Operational Excellence to track this, and then standardize education around it,” said Hastings.

Operational Excellence is a program that brings leaders and team members together to engage in work focused on improving safety, quality and patient experience. Beginning with Pen Bay Medical Center in 2013, Operational Excellence has since been rolled out at every organization across the MaineHealth system, with hundreds of departments participating systemwide and thousands of improvement initiatives completed.

Talking Directly with Teams

One aspect of this program is the Gemba Walk, where leaders visit numerous departments every day, to talk directly with teams about the work being done there. Department personnel collect data on the issues they wish to improve — summarized as Key Performance Indicators (KPIs) that are measured and tracked daily — and share this information at the Gemba Walk.

Hastings and her team determined that their KPI would track the Birth Center’s safe sleep environment, defined as no extra blankets, pillows or stuffed animals in a crib — baby only. PBMC lactation consultant Dawn Tassi, RN, IBCLC, developed the KPI and the entire team tracked it. If the nurses observed a crib with a stuffed animal in it, they provided education to the family; if they saw a baby wrapped in blanket or comforter, they showed parents how to use the sleep sack. The nursing team was engaged in every aspect of the safe sleep initiative. “As a result of the data we collected from this KPI, we determined we needed to develop a department-based safe sleep policy to address the infant safe sleep program; not just prenatally, but here in the hospital and after the babies have gone home,” said Hastings. Alisa Kidney, RN, CLC, a newly hired PBMC nurse, enthusiastically volunteered to create the safe sleep policy.

“OpEx provided us with a vehicle to be thoughtful; to let the data define a problem, and to help us focus on what could we do about it. Sometimes you need a process in place to reveal these kinds of details; it’s easy for meetings or other work to take priority,” Hastings said.

The Birth Center team’s actions position PBMC to meet the eligibility requirements for “Bronze Certification” by the Cribs for Kids hospital certification program, which is recognized by the National Institutes of Health and the American Academy of Pediatrics as the national standard for safe sleep of infants.

System-Wide Commitment to Operational Excellence

This story of collaboration, excellence and commitment to outstanding patient care is one of many across the MaineHealth system. In fact, in recognition of its system-wide commitment to Operational Excellence, MaineHealth was awarded the 2017 Quality Improvement Leadership Award from Maine Quality Counts, a nonprofit organization working to transform health and health care. This award recognizes an individual or organization that has introduced innovations, used creativity and embraced risk-taking in leadership of demonstrably successful quality improvement initiatives.

“MaineHealth has made an unprecedented effort toward engaging all of our member organizations in quality improvement,” said Jordan Peck, PhD, senior director of the MaineHealth Center for Performance Improvement. “The QC Quality Improvement Leadership Award is a testament to the incredible progress we’ve made as a system toward building a culture of continuous improvement.”

 “Operational Excellence has shown us that we can solve our problems together using creative and innovative solutions,” added Peck.

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