NEWS


Harborview sheds convenience store mindset for luxury department store operation

Within months, complaints turned
to compliments
 

When you’re searching for ideas to improve something – be it a process, a product or even a relationship – you might be surprised how, when and where the light bulb flicks on. Typically, it happens in the unlikeliest of places involving the unlikeliest of circumstances.

As a Level 1 trauma and burn center for five states in the Pacific Northwest, the emergency department, operating room and intensive care units at Seattle-based Harborview Medical Center simply can’t afford a supply chain crisis – even merely a crisis of confidence.

With an average daily inpatient census consistently exceeding 95 percent, all three departments, particularly the critical care ICU, are very supply and equipment dependent. Because the facility’s trauma patient population is both "unpredictable and complex," according to Delores Kannas, R.N., MSN, CCRN, manager, inventory management and distribution services, clinicians in those departments expect a high level of service to provide care.

Front row: Becky Pierce, assistant administrator of Patient Care Services; Johnese Spisso, chief operating officer.

Unfortunately, up until roughly four years ago, that wasn’t the case. "The level of service being provided was so low the nursing staff had declared a crisis," said Kannas, also a trauma ICU staff nurse. "Something needed to be done."

What they did was emulate a popular and successful program in pharmacy, adapting it for critical care supply functions, implement a "lean strategy" to organize supply rooms, install an ICU nurse to lead the service department responsible for making it happen and encourage staff nurses to increase their involvement in supply chain activities.

Such strategic thinking, teamwork and turnaround success inspired Healthcare Purchasing News to name Harborview its 2006 Critical Care Supply Innovator.

Pharmacy know-how

Back in the early 1990s, Harborview’s pharmacy struggled with medication errors and other nursing-related service-oriented problems that prompted the department to search for solutions. Ultimately, pharmacy found success by designing and implementing a "unit pharmacy technician" (UPT) service to deliver medications and solutions to the patient care units. Thanks to the UPTs and improved communications, medication errors and nursing complaints decreased significantly and pharmacy’s historical service problems eventually faded into the background.

The nurses, however, didn’t forget how well the UPTs worked for pharmacy and began asking for a similar service to solve their supply and equipment problems.

But the requests fell on deaf ears. Instead of designing and implementing a service similar to pharmacy’s for supplies and equipment, the hospital focused on making personnel changes and working harder using established practices to improve distribution problems. Nothing seemed to work effectively. Someone raised the UPT idea again and its success rate, this time suggesting it to Douglas Knorr, administrative director of supply chain management.

Consequently, in 1999, he helped draft a proposal for a "unit supply technician" (UST) service that garnered no financial support. Nearly three years and numerous complaints later, administration gave the UST proposal the green light, granting Knorr additional staff to launch a pilot program in November 2002.

Unlocking potential

Even though Harborview had implemented a just-in-time (JIT) delivery service with its external distributor, Cardinal Health Inc., internal service languished, according to Kannas. "Supply closets were poorly organized and high-use items were in scarce supply while low-use items were overstocked, adding to the clutter and taking up space," she said. "Each unit’s supply closet had supplies arranged differently, which added stress and delays in locating items, especially for nurses and residents who were required to work in multiple units. These conditions were chronic and created a great deal of tension between the nurses and the distribution staff."

Delores Kannas, manager of Inventory Management and Distribution Services, shows unit supply technicians Farris "Tip" Hinton and Marcus Wiley pumps at the nurses’ station on the Trauma Intensive Care Unit.

As a result, morale among the distribution staff, known as stockroom attendants, plunged and staff turnover exceeded 50 percent. "Effective communication, trust, and successful problem solving behaviors between the stockroom attendants and nursing staff did not exist," she added. "The system was broken and in need of new tools to fix the problem."

In 2002, a nursing staff survey confirmed what had been overheard for some time: Anecdotal reports of critical incidents associated with not having the right supplies and equipment for patient care in the ER, OR, ICUs and acute care units, according to Kannas. Johnese Spisso, R.N., Harborview’s chief operating officer, learned of the problems and quickly launched a project to improve processes hospital-wide.

The project encompassed two parallel initiatives that would move forward in phases and help the facility find new tools to fix what was broken.

Cynthia Hecker, R.N., associate administrator and chief nursing officer, joined forces with Knorr to spearhead a structural strategy that initially involved installing akrobins in the patient care area supply rooms, Kannas recalled. Then the team recruited external consultants to work with Barbara Fetty-Solders, R.N., clinical instructor in patient care services (PCS), to develop a lean management approach that included rapid process improvement projects (RPI).

Harborview implemented the first RPI in the pharmacy using the Lean Strategy "5 S" tools (simplify, sort, sweep, standardize and sustain) to decrease wait time in outpatient pharmacy. Once completed, Fetty-Solders began systematically working with teams of nurses and USTs in each patient care unit to apply RPI and the lean strategy to clean supply rooms.

At the same time in 2002, Robert Hamilton, associate administrator for clinical support services, formed the Supply Chain Re-Engineering Task Force to more clearly define the problems and find new solutions using the UST service model proposal, adding a clinical liaison position to help implement the UST service – Kannas, a trauma ICU staff nurse. The task force leaders included Knorr, Kannas, Sandra Buckingham, assistant director, procurement services, supply chain management; Becky Pierce, R.N., assistant administrator, patient care services; Susan Manfredi, R.N., assistant administrator, patient care services; and Neil Francoeur, R.N., nurse manager, trauma ICU/radiology.

Within six months, Kannas, a registered nurse with more than three decades of ICU experience was chosen to manage the distribution department, and the medical stores name changed to inventory management and distribution services. Centralized stockroom attendants were reclassified as decentralized USTs with more responsibilities and higher wages. Each is assigned to a small number of units to manage inventory and deliver supplies and equipment. As part of the healthcare team, they are expected to be accountable, responsible problem-solvers and communicators, Kannas emphasized. Consequently, departmental morale improved, and staff turnover dropped to less than 10 percent. Kannas also hired Kirby Nelson as assistant manager with nearly 20 years of materials management experience to solidify the leadership expertise in her department.

Lean, mean and pristine

Kannas freely admitted that the "5 S" lean management techniques to organize the supply rooms, as well as the creation of the UST service represented the tentpoles in building camaraderie between the clinical and supply staffs. Using the RPI and 5 S strategies to simplify, sort, sweep, standardize and sustain the gains in the supply rooms effectively brought unit leaders and nurses together with USTs and UST leads to plan solutions.

Delores Kannas, manager of Inventory Management and Distribution Services, and Marviolyn Belen, stockroom attendant with Medical Stores, stock items on the Trauma Intensive Care Unit.
 

"The end result is that the nurses can find their ‘stuff,’ and the UST’s job of inventory and re-stocking is much easier," Kannas said. "Empty bins are easily spotted and filled before a critical need arises. Having standard strategies for organizing supplies across different units has helped nurses who float and residents who work in multiple units find supplies much more quickly. Not only are clinicians and USTs not wasting time now that supplies are better organized, better management of stocking levels has resulted in a significant decrease in the dollars invested in inventory on the shelves because the hoarding behaviors nurses relied on in the past have been eliminated."

Developing the UST role also helped the supply staff understand how products and equipment are used for patient care, which enables them to "more appropriately prioritize their inventory management and distribution activities," Kannas noted. Equipped with pagers, the USTs are available 24/7 and interact daily with nurses who now rely on them to solve any supply and equipment problems, she added. They work 12-hour shifts, have change-of-shift reports and adjust supply PAR levels as needed to meet changing demands. A dedicated UST team cleans and distributes equipment, using bar codes and a computer database to minimize turnaround time.

"Critical care nurses want their ‘stuff’ when they need it," Kannas continued. "They typically do not pay close attention to supplies or equipment unless they are not available or they are the wrong products. The nurses want materials management to know what they need and to insure that they can quickly find what they need at all times. Beyond this basic requirement, these nurses want a say in the selection of new products and equipment. Their workflow and patient safety depend on the ease of use and minimization of risk associated with the tools they use to provide care."

The choice of Kannas, a veteran ICU nurse with more than 30 years experience who works every other Friday in the trauma ICU, to lead the distribution department also represented a novel approach to overcoming supply challenges. Appointing someone with such a vast amount of clinical expertise over a logistics function, rather than having them focus on direct patient care doesn’t happen very often.

"We need someone who speaks the nurses’ language, can translate their needs and feels their pain," she said. "This is the key reason why I continue to work every other Friday in the trauma ICU. My success is directly tied to the level of credibility and sensitivity to nurses’ issues that I am able to maintain from this continued involvement in patient care. On the other side, I am able to use opportunities while working at the bedside to explain supply chain management to nurses using real examples to answer questions. The integration of supply chain management and patient care services is essential to the success of both entities. Positioning the manager of distribution services in a patient care role has greatly assisted this integration for us."

Harborview’s RPI teams received capable assists from Cardinal, which increased JIT deliveries to seven days a week from five (Monday through Friday), effectively decreasing complaints about stockouts from nurses, and dedicated a representative to participate in the weekly project meetings. As a member of University HealthSystem Consortium (UHC), Harborview relies on Novation for supply contracting services. UHC also furnished the teams with education, benchmarking and networking opportunities along the way. "UHC conference opportunities have played a major role in providing me with supply chain management knowledge and exposure to new ideas through networking with leaders in like facilities who are facing similar challenges," Kannas added.

Common ground

Through it all, Harborview encourages staff nurses to become more actively involved in product evaluation by participating in focus groups that make recommendations to the product evaluation committee based on clinical criteria.

"Joint decision making between supply chain management and critical care nurses is a challenge because the priorities can be very different between the two groups," she said. "For example, making a multi-million dollar decision on new ‘smart pump’ technology or bar coding supplies can test the strength of the relationship due to their very different ‘views of the world.’ The more the two groups use a commonly understood language, the more successful these change processes will be. Our product evaluation committee is the common meeting ground for these ‘two worlds’ to come together and achieve a common understanding."

Adopting retail models

Kannas encapsulates Harborview’s efforts and accomplishments as migrating to a prominent luxury department store model from a popular convenience store model, perhaps an appropriate allusion from the retail industry.

"Customer satisfaction is gained by matching customer needs with specifically designed services," she noted. "In the convenience store model, the customer is looking for quick access to a limited stock of products with minimal decision making and minimal service required. As customer needs intensify and become more complex, so should the level of service. Critical care nurses depend heavily on medical supplies and equipment to provide patient care. The [luxury department store] model stresses individual customer attention provided by someone who is an expert in the field and can access additional resources to insure the customer’s needs for high quality goods are met."

Achieving successes breed more successes, she continued. "We have changed complaints to compliments. We still have problems, but we address them and make the necessary changes to insure they do not become chronic problems." HPN

June
2006