Reply to two (2) different class peers, extending the discussions by contributing new ideas and information. Replies should have at least a 150 word-count. Support each of your discussion with at least two (2) citations from recent, peer-reviewed ariticles
Peer 1: The three wastes within my organization are defects, transportation, and inventory. Graban (2016), identified various types of waste that adversely impacts the effectiveness, efficiency, productivity, and profits of any organization. Additionally, Graban mentioned that these types of waste can be found in organizations inclusive of the medical, fabrication, manufacturing, and tourism. Realyvasquez-Vargas, Arrendondo-Soto, Carrillo-Gutierrez & Ravelo (2018), echoed Graban’s thoughts. Throughout their research, they provided numerous examples of various wastes and the loss of profits, products, and efficiency for each type of waste incurred within an organization. No organization is free from these types of waste.
One of the defect wastes within my organization is patients arriving from either the ED or ICU with a catheter, but no orders for the catheters or even a qualifying factor for catheter placement. This has been an ongoing issue since the start of my employment. I have brought it up at our one and only nurse advisory council meeting, and our Infectious Disease nurse, Unit Managers, and CNO had come on board to advise nurses that this practice is not acceptable. But they still keep arriving, and nothing appears to be done about stopping this practice. As Charge Nurse, I request all of my nurses to question if an order exists for the foley, and if not demand that either the foley be removed or an order be written. Some nurses are not as diligent in doing so, thus patients arrive with unordered foleys. My nurses then have to do a thorough chart check to look for the order set, and if it does not exist, then we take out the foley. The specific wastes in this situation are loss of inventory; loss of time for the nurse inserting the foley; loss of time for the nurse doing the chart check and foley removal; and loss of best practice integrity.
Another defect waste is patients arriving with more than one IV site. Whenever the ED needs to do a blood draw on a patient, instead of using a butterfly to draw the sample and then discarding the butterfly, they just place another IV. Within the ED, they are authorized a blood draw on the initial IV stick, so that is their practice. It appears the ICU does the same, or they just leave in the many IVs. Its common for a patient to arrive with two or three IVs, with the transferring nurse mentioning that he placed another IV, because the former IV was not working well, but the patient arrives with the non-functioning IV in place. I even have patient arriving with a PICC or central line, as well as the IVs. Just last week I took report on a patient that was arriving with a triple lumen IJ and three IVs, and the patient was saline locked. The wastes here are of course: increases in sepsis potential; discomfort to the patient; and an appearance of nurse laziness.
Transportation is the 2nd waste, and I am sure this could be a problem for any one of us due to the space confinements. As mentioned in my earlier discussion, my unit has three storage closets, with one each being located at either end of a 200-foot hallway. Besides these closets, our lifts, bedside commodes, and blanket warmer is just outside our unit in yet another old patient room. Another transportation defect is that we have to leave our unit and travel down four floors to collect expensive medications from our pharmacy, because our policy does not allow expensive medications to be moved via the tube system. Our inclusive wastes are loss of efficiency and time.
The third waste is inventory. Using the example above about the inadvertent foley placement. The foley itself must be thrown out, thus we use some inventory for no good purpose. Another material waste is the excess supplies taken into a patient’s room. It appears that with each shift, either the CNA or nurse takes in their expected needed supplies, without taking inventory of what is already in the room. I have visited a patient’s room and saw two or three linen sets, and then to top that off, I will see my CNA taking another arm load into the room in preparation for his shift. Approx. 50% of our patient rooms may have upwards of five or more packets of hygiene wipes, two or more urinals, and mounds of wound care items. All of these have to be disposed of when the patient discharges. The inventory cost is a direct hit on profit sharing, since thrown out items have to be replaced, and the expenditure to return on profits decreases, thus our profits decrease, which in turn decreases our profit sharing return for our non-profit hospital. Inclusive wastes of this kind are inventor, profit sharing, and ecological damage since now we are putting good items into the landfills.
The method of observation is the effort that it takes for my nurses to undo the waste that others have created. We have to waste our time to undo the unwarranted errors that other nurses have deliberately done.
The higher echelon is surprised because they do not walk around and witness the actual activities within the hospital. When I challenged the foley issue during the only nurse council meeting, the CNO, Unit Managers, Infections Disease Nurse, and the Quality Assurance Nurse had no idea of the number of unordered foleys in-place or the number of patients arriving with two or more IVs in-place . If the managers visited the units and questioned why a foley was in place, or visited the ED or ICU and counted the number of patients with more than one IV, then they would see the abuse of our patients, as well as a potential contributor to our hospital acquired infections.
But the overall issue that allows these wastes to occur is that the higher echelon were self-starters and disciplined nurses who out-performed others and followed procedures. Their performance did not place the patient in harm’s way. In turn they expect that all other nurses are the same. The leaders had a solid work ethic; thus, they just believe that all others share the same philosophy – unfortunately, some nurses do not. They need to get out into the workplace and do some “walking around” management with a stern observation mannerism.
This time, the reading made me rethink the various methods of waste within my organization, to try to make my unit see them. I also can prepare a list of hospital-wide wastes, as well as the mapping to outline the waste and provide a few suggestions on ways to minimize the wastes. I now have an open door to the CNO since she is my preceptor for my practicum. I will not use the practicum as my forum, but if she asks for any inputs related to this, then I will be prepared to give her honest, mostly factual feedback.
Graban, M. (2016). Lean hospitals: Improving quality, patient safety, and employee engagement (Third edition). Productive Press.
Realyvasquez-Vargas, A., Arredondo-Soto, K. C., Carrillo-Gutierrez, T., Ravelo, G. (2018). Applying the Plan-Do-Act (PDCA) cycle to reduce the defects in the manufacturing industry. A case study. Applied Sciences 8(11). p 25-35. DOI:10.3390/app81121
Peer 2: Which types of waste are most prevalent in your department or organization? Provide at least 3 examples.
As waste is described by Graban, (2016), I have to view the following as the most prevalent forms of waste: printing, efficient use of EHR for tasks and communication, and multiple sources for prescription refill requests.
Certain reports such as orders and lab results are printed on paper and these are passed around the office to the ordering provider for review. On occasion, these reports were received by fax, then scanned into the patient’s chart, then reprinted. These reports can just be uploaded into the patient chart and then attached for an individual user to review.
This concept ties into efficient use of the EHR for tasks. The EHR is a smart system and has many capabilities for use in communication between users and between providers and patients. Each provider operates in a different manner and some hand physical paper requests for nurses to contact patients, others task electronically. With consistency, less waste would occur that would allow for more efficient patient communication.
Some pharmacies fax paper refill requests, others send electronic refill requests, and some pharmacies call for authorizations. Some pharmacies fax a response for a live signature once an electronic order was submitted. This creates many forms of waste.
What types of observation was made to determine the waste in your department or organization?
The observation used to determine waste can best be described by looking for areas that time was sent unnecessarily. McBride, 2003, helped define 7 different areas of common waste in manufacturing. Of the seven listed, unnecessary or excess motion, waiting and defects were all good identifiers for wastes.
Why are/how were people surprised by what we see when observing the process and discussing our observations with colleagues?
The mention of waste and correlating to use of time and inefficient use of EHR was not initially well received when the discussion was presented. Initially people became defensive when it was related to their personal preferences and processes. And some folks were not exactly ready to listen.
How have the readings and discussion helped you achieve your SLOs?
The readings have helped to determine ways to introduce more efficient use of current resources as to maximize production and improve communication and patient satisfaction.
Graban, M. (2016). Lean Hospitals: Improving Quality, Patient Safety, and Employee
Engagement. (3rd ed.) Boca Rotan, FL: CRC Press
McBride, D. (2003). The 7 Wastes in Manufacturing.
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