GIM Clinical Assessment and Optimization Project

Description of problem or project: An opportunity exists in general internal medicine clinic to optimize nursing (RNs, LPNs, and MA staff) efficiencies, standardize the work and improve current practice and work load, and determine the best staffing and skill mix. A national staffing determination survey (2016) was conducted in internal medicine that recommended a total number of nursing staff which is substantially less than previous staffing plans. The recommendations include a total number RN/LPN/MA FTE of 15.7. Current staffing is 17 FTE, down from 20+ a year ago. The remaining 6-team nurses have absorbed the work of 1.8 care managers. Overtime and float nurse use has increased greatly in a year. Nursing turnover has increased. Nursing and MA work processes lack standardization and control. Both roles have perceived difficulty in role delineation and teamwork. Data suggests an increase in near misses and errors. Staff report high levels of stress and concern for their workload. Providers report concern regarding less staffing support, patient dissatisfaction, and high levels of stress.

The goals of the project are to measure the volume and types of work that the RNs, LPNs, and MAs perform and to delineate the right work and the right number of people.

Methodology: This project utilizes Lean Six Sigma methodology to define, measure, analyze, implement, and control processes. The current state of nursing in general internal medicine clinic is measured by reviewing volumes of encounters, observation of staff performing tasks, including timed studies, tallying hot line calls, use of treatment rooms, tracking unplanned absences, use of float nurses, and overtime. By understanding the volume of services and task times, it is believed that the clinic will be better able to estimate correct staffing.

Analysis: Through observations and initial data analysis, several solutions were implemented which fixed challenging processes. These quick wins included the purchase of a cell phone for patient hot line calls, which has reduced the number of missed urgent calls and the creation of a daily all-staff safety huddle. The safety huddle has provided better communication to staff for the day-to-day running of the clinic allowing them to feel more prepared. There has also been an increase in reporting of events in clinic that effect patient and/or staff safety. The clinic also received approval to hire an extra nurse.

Results: Data is currently analyzed and several improvements have been implemented. The team has functioned well and maintained “on-time” status throughout the project. The planned project end date is January of 2019.