Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
496121
research-article2013
NASXXX10.1177/1942602X13496121NASN School Nurse / Month XXXXMonth XXXX / NASN School Nurse
Feature Article
Learning and Applying New Quality Improvement Methods to the School Health Setting Laurel A. Celik, BSN, RN, NCSN
A school health registered nurse identified medication administration documentation errors by unlicensed assistive personnel (UAP) in a system of school health clinics in an urban setting. This nurse applied the Lean Six Sigma Define, Measure, Analyze, Improve, Control process of improvement methodology to effectively improve the process. The UAP of medication administration documentation error rate improved from 68% to 35%. This methodology may be used by school nurses to collaboratively look at ways to improve processes at the point of care. Keywords: medication; documentation; professional practice; personnel management
A
literature review revealed common areas of concern regarding medication administration errors in the school setting: missed medication doses, documentation errors, double medication doses, and administration of
a medication to the wrong student (Farris, McCarthy, Kelly, Clay, & Gross, 2003; Ficca & Welk, 2006; Price, Dake, Murnan, & Telljohann, 2003). Medication errors related to unlicensed assistive personnel (UAP) and school personnel in the school setting occur frequently (Richmond, 2011). Capturing the frequency and types of medication error rates is important for gauging the scope of the problem, setting priorities for prevention strategies, and measuring the impact of those strategies. School nurses have the responsibility to establish processes to assure student safety. Despite identifying a variety of medication errors documented in the school setting, the literature does not provide recommendations for methods to reduce the problem. In 2010, a school health registered nurse conducted monthly audits of medication documentation sheets and identified a 68% medication documentation error rate in 26
elementary and middle schools in an urban school district in Akron, Ohio. Documentation errors included any time there was a discrepancy in the documentation of the amount of medications remaining and the count of the actual medication. The UAP had primary responsibility for medication administration. These documentation errors are associated with potential for medication errors (e.g., missed doses, double doses) and medication theft. The challenge became identifying the reason—by first looking at the process and why the documentation errors occurred. This nurse applied the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) process improvement methodology to effectively improve the process. The Akron Children’s Hospital Institutional Review Board (IRB) chair deemed the quality improvement project exempt from IRB review. The Lean Six Sigma A3 process provides a means to
DOI: 10.1177/1942602X13496121 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015 © 2013 The Author(s)
November 2013 | NASN School Nurse 307
Figure 1. Fishbone Diagram Medication Documentation Errors
methodically address and solve problems while providing quality improvement tools to produce sustainable change within an 8-week timeframe. The health care industry has adopted Lean Six Sigma processes from manufacturing to look at what the work staff does at the point of care to improve quality and safety by eliminating process defects and waste to create a sustainable change (Ghosh, 2012). The A3 methodology provided a systematic approach to process improvement. This project is described using the DMAIC steps outline (Ghosh, 2012; Jimmerson, 2007).
308 NASN School Nurse | November 2013
Method Team Formation The nurse (project lead) partnered with a hospital-based Lean Six Sigma coach and formed a team composed of the nurse manager (process owner) and point of care staff (UAP). The coach provided education and coaching on the process and a resource training manual (Center for Operations Excellence, 2012). Define/Measure In the first step in the DMAIC methodology, defining the scope of the project, the team narrowed medication
errors to documentation of medications due to the rate and potential impact on safety. The team considered this a specific problem with a feasible project scope. The problem statement guiding the project was “Lack of documentation of medication administration is leading to an increase in error reports.” The objective statement for the project was to “Decrease the number of error reports from medication errors due to documentation errors of staff administering medication by 75% by December 2011.” Next , the nurse observed the process used by the UAP to gather essential data
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
Figure 2. Documentation of Medications: Errors—Current Value Stream Map
about the current state. Asking the stakeholders (UAP) why they thought documentation errors were occurring in the medication administration record
(MAR) served as the most important step in this process. The team completed a fishbone diagram to identify and organize possible factors contributing to
the documentation errors in a structured format (see Figure 1). The team approach to problem solving often results in numerous opinions about the problem’s root cause. One way to capture these different ideas and stimulate the team’s brainstorming is the cause and effect diagram, commonly called a fishbone. The fishbone visually displays the potential causes for a specific problem. Because people often like to start with identifying solutions to a problem, the fishbone can help team members conduct a more thorough exploration of the issues behind the problem, which leads to a more robust solution. When constructing the fishbone, the school nurse started with stating the problem in the form of a question, such as “Why is the medication documentation error rate so high?” Framing it as a “why” question will help in brainstorming, as each root cause idea should answer the question. This question is placed in a box at the “head” of the fishbone. The rest of the fishbone then consists of one line drawn across the page, attached to the problem statement, and several lines, or “bones,” coming out vertically from the main line. These branches are labeled with different decided upon categories (Center for Operations Excellence, 2012). The fish bones provide the description of the factors and the fish head describes the main problem. Emerging themes included busy days in clinics, disorganization of the medication cabinets and MAR, competing priorities during recess, forgetting to document medication administration, and not counting the remaining medications in the storage container. Creation of a current state value stream map (a picture of the process) depicted the current medication administration process in the school clinics (see Figure 2). While the medication administration process has very specific steps, many problems or “storm clouds” associated with the current process interfered with completion of the proper steps. The team addressed a few crucial storm clouds during the scope of the project.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
November 2013 | NASN School Nurse 309
Analyze The concept of asking a series of causal questions is simple yet peels away at layers of symptoms to determine the root cause. The team used the “5 Whys” tool and asked questions until the root cause of the problem was determined.
Figure 3. Documentation of Medications: Errors—Future State Value Stream Map
1. Documentation errors are occurring in the MAR. Why? 2. Unlicensed staff is not following the medication procedure. Why? 3. Unlicensed staff becomes too comfortable in this daily procedure. Why? 4. Unlicensed staff does not understand the importance of the MAR. Root Cause: Documentation errors are occurring because unlicensed staff does not understand the importance of proper documentation with medication administration. Improve The team developed standard work instructions (SWI) to provide clear directions for the best process to use for medication administration at that point in time. The school nurse initiated the SWI in the clinics by reviewing them with the UAP, posted them on the medicine cabinet, and placed a copy in front of the MAR in each health clinic. The next step was to organize the MAR with tabs for daily medications, diabetes medications, per diem medications, self-carry medications, and discontinued medication orders. These SWI outlined the chronological steps in the process to avoid an error. The steps included (1) Open MAR, (2) Ask student name and birth date, (3) Unlock med cabinet and find med, (4) Verify 5 Rights, (5) Compare medication to medication record 3 times, (6) Give medication, (7) Write it! Document date, time given, (8) Count and document remaining pills, (9) Sign MAR, and (10) Close MAR (Akron Children’s Hospital, 2013). The SWI were printed as color 8½ by 11 sheets, laminated, and posted on the medication cabinets in the 26 school health clinics.
310 NASN School Nurse | November 2013
Control The school nurse conducts a monthly reconciliation by reviewing medication orders against the MAR. If there are discrepancies, the school nurse records a medication documentation error report and provides re-education to the UAP. On a monthly basis, data are analyzed,
evaluated, and reviewed with the UAP, nurse manager, and nursing director. Next, the team created a future state value stream map depicting the envisioned process (see Figure 3). To achieve the targeted state, the school RN met with all UAP to discuss SWI to prevent documentation errors.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
Figure 4. Documentation Errors
Data were collected monthly to track and trend the documentation error rate following implementation of SWI. The UAP knew that the medication records would be closely observed at least once a month.
Results Following implementation of the SWI in September 2011, the UAP developed an increased awareness of the importance of an accurate medication count with documentation required after each dose is given to the student. For example, the UAP caught pill count errors including errors attributable to theft, errors by staff temporarily assigned to work in the clinic, and teachers or staff giving the medication after clinic hours. From September 2011 through June 2012, the clinics realized an 18% decrease in documentation errors. For a total of 16,836 medications administered during that timeframe, there was a total of 16 documentation errors (see Figure 4). Considering the large total number of medications administered in the school clinics, the error reports decreased dramatically.
Implications for School Nursing The A3 process was successful for several reasons. First, problem solving was a shared experience between the school nurse and the UAP. Collaboratively, point of care staff
identified barriers and solutions to decrease medication documentation errors to improve student safety. Second, all stakeholders actively looked for ways to improve student safety by reducing medication administration documentation errors. Medication error rates declined overall with increased monitoring and audits of the process. Licensed and unlicensed staff temporarily assigned to the clinic accounted for three of the documentation errors. This leads to the potential for more detailed review of SWI with temporarily assigned staff and teachers. Now that a process is in place, the challenge will be to sustain a continued decrease in medication administration documentation errors. The SWI also allowed for prompt identification of medication theft from the clinic after school clinic hours. The DMAIC process can be replicated by any personnel involved in medication administration in the school setting to enhance safety practices.
Conclusion This project aligns with recommendation two of the Institute of Medicine’s (2010) The Future of Nursing: Leading Change, Advancing Health, which calls for nurses to engage in quality improvement efforts. The author had the opportunity to learn a new process improvement methodology with teaching and coaching from a qualified nurse employed by the health care organization. The diffusion of the successful practice also aligns with this recommendation. School nurses can ensure safe health care in the school setting by learning and implementing quality improvement methodologies. ■
Acknowledgments The author wishes to thank Sheryl Valentine, MBA, BSN, RN, MBOE, Center for Operations Excellence, Akron Children’s Hospital, for assistance with the A3 project; Cheryl Christ-Libertin, DNP, CPNP-PC, Center for Professional
Practice, Akron Children’s Hospital, for assistance with manuscript preparation; and Michele Wilmoth, MSN, RN, manager of School Health Services, Akron Children’s Hospital, for support with the A3 project.
References Akron Children’s Hospital. (2013). School health services standard work instructions medication administration. Akron, OH: Akron Children’s Hospital. Center for Operations Excellence. (2012). A3 training manual. Akron, OH: Akron Children’s Hospital. Farris, K. B., McCarthy, A. M., Kelly, M. W., Clay, D., & Gross, J. N. (2003). Issues of medication administration and control in Iowa schools. Journal of School Health, 73(9), 331-337. Ficca, M., & Welk, D. (2006). Medication administration practices in Pennsylvania schools. The Journal of School Nursing, 22(3), 148-155. Ghosh, M. (2012). A3 process: A pragmatic problem-solving technique for process improvement in health care. Journal of Health Management, 14(1), 1-11. Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jimmerson, C. (2007). A3 problem solving for healthcare. New York, NY: Productivity Press. Price, J. H., Dake, J. A., Murnan, J., & Telljohann, S. K. (2003). Elementary school secretaries' experiences and perceptions of administering prescription medication. Journal of School Health, 73(10), 373-379. Richmond, S. L. (2011). Medication error prevention in the school setting. NASN School Nurse, 9, 305-308.
Laurel A. Celik, BSN, RN, NCSN School Health RN District Supervisor School Health Services Akron Children’s Hospital Akron, OH Laurel is the school health RN district supervisor for 23 health aides in an urban school district.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
November 2013 | NASN School Nurse 311
496121
research-article2013
NASXXX10.1177/1942602X13496121NASN School Nurse / Month XXXXMonth XXXX / NASN School Nurse
Feature Article
Learning and Applying New Quality Improvement Methods to the School Health Setting Laurel A. Celik, BSN, RN, NCSN
A school health registered nurse identified medication administration documentation errors by unlicensed assistive personnel (UAP) in a system of school health clinics in an urban setting. This nurse applied the Lean Six Sigma Define, Measure, Analyze, Improve, Control process of improvement methodology to effectively improve the process. The UAP of medication administration documentation error rate improved from 68% to 35%. This methodology may be used by school nurses to collaboratively look at ways to improve processes at the point of care. Keywords: medication; documentation; professional practice; personnel management
A
literature review revealed common areas of concern regarding medication administration errors in the school setting: missed medication doses, documentation errors, double medication doses, and administration of
a medication to the wrong student (Farris, McCarthy, Kelly, Clay, & Gross, 2003; Ficca & Welk, 2006; Price, Dake, Murnan, & Telljohann, 2003). Medication errors related to unlicensed assistive personnel (UAP) and school personnel in the school setting occur frequently (Richmond, 2011). Capturing the frequency and types of medication error rates is important for gauging the scope of the problem, setting priorities for prevention strategies, and measuring the impact of those strategies. School nurses have the responsibility to establish processes to assure student safety. Despite identifying a variety of medication errors documented in the school setting, the literature does not provide recommendations for methods to reduce the problem. In 2010, a school health registered nurse conducted monthly audits of medication documentation sheets and identified a 68% medication documentation error rate in 26
elementary and middle schools in an urban school district in Akron, Ohio. Documentation errors included any time there was a discrepancy in the documentation of the amount of medications remaining and the count of the actual medication. The UAP had primary responsibility for medication administration. These documentation errors are associated with potential for medication errors (e.g., missed doses, double doses) and medication theft. The challenge became identifying the reason—by first looking at the process and why the documentation errors occurred. This nurse applied the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) process improvement methodology to effectively improve the process. The Akron Children’s Hospital Institutional Review Board (IRB) chair deemed the quality improvement project exempt from IRB review. The Lean Six Sigma A3 process provides a means to
DOI: 10.1177/1942602X13496121 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015 © 2013 The Author(s)
November 2013 | NASN School Nurse 307
Figure 1. Fishbone Diagram Medication Documentation Errors
methodically address and solve problems while providing quality improvement tools to produce sustainable change within an 8-week timeframe. The health care industry has adopted Lean Six Sigma processes from manufacturing to look at what the work staff does at the point of care to improve quality and safety by eliminating process defects and waste to create a sustainable change (Ghosh, 2012). The A3 methodology provided a systematic approach to process improvement. This project is described using the DMAIC steps outline (Ghosh, 2012; Jimmerson, 2007).
308 NASN School Nurse | November 2013
Method Team Formation The nurse (project lead) partnered with a hospital-based Lean Six Sigma coach and formed a team composed of the nurse manager (process owner) and point of care staff (UAP). The coach provided education and coaching on the process and a resource training manual (Center for Operations Excellence, 2012). Define/Measure In the first step in the DMAIC methodology, defining the scope of the project, the team narrowed medication
errors to documentation of medications due to the rate and potential impact on safety. The team considered this a specific problem with a feasible project scope. The problem statement guiding the project was “Lack of documentation of medication administration is leading to an increase in error reports.” The objective statement for the project was to “Decrease the number of error reports from medication errors due to documentation errors of staff administering medication by 75% by December 2011.” Next , the nurse observed the process used by the UAP to gather essential data
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
Figure 2. Documentation of Medications: Errors—Current Value Stream Map
about the current state. Asking the stakeholders (UAP) why they thought documentation errors were occurring in the medication administration record
(MAR) served as the most important step in this process. The team completed a fishbone diagram to identify and organize possible factors contributing to
the documentation errors in a structured format (see Figure 1). The team approach to problem solving often results in numerous opinions about the problem’s root cause. One way to capture these different ideas and stimulate the team’s brainstorming is the cause and effect diagram, commonly called a fishbone. The fishbone visually displays the potential causes for a specific problem. Because people often like to start with identifying solutions to a problem, the fishbone can help team members conduct a more thorough exploration of the issues behind the problem, which leads to a more robust solution. When constructing the fishbone, the school nurse started with stating the problem in the form of a question, such as “Why is the medication documentation error rate so high?” Framing it as a “why” question will help in brainstorming, as each root cause idea should answer the question. This question is placed in a box at the “head” of the fishbone. The rest of the fishbone then consists of one line drawn across the page, attached to the problem statement, and several lines, or “bones,” coming out vertically from the main line. These branches are labeled with different decided upon categories (Center for Operations Excellence, 2012). The fish bones provide the description of the factors and the fish head describes the main problem. Emerging themes included busy days in clinics, disorganization of the medication cabinets and MAR, competing priorities during recess, forgetting to document medication administration, and not counting the remaining medications in the storage container. Creation of a current state value stream map (a picture of the process) depicted the current medication administration process in the school clinics (see Figure 2). While the medication administration process has very specific steps, many problems or “storm clouds” associated with the current process interfered with completion of the proper steps. The team addressed a few crucial storm clouds during the scope of the project.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
November 2013 | NASN School Nurse 309
Analyze The concept of asking a series of causal questions is simple yet peels away at layers of symptoms to determine the root cause. The team used the “5 Whys” tool and asked questions until the root cause of the problem was determined.
Figure 3. Documentation of Medications: Errors—Future State Value Stream Map
1. Documentation errors are occurring in the MAR. Why? 2. Unlicensed staff is not following the medication procedure. Why? 3. Unlicensed staff becomes too comfortable in this daily procedure. Why? 4. Unlicensed staff does not understand the importance of the MAR. Root Cause: Documentation errors are occurring because unlicensed staff does not understand the importance of proper documentation with medication administration. Improve The team developed standard work instructions (SWI) to provide clear directions for the best process to use for medication administration at that point in time. The school nurse initiated the SWI in the clinics by reviewing them with the UAP, posted them on the medicine cabinet, and placed a copy in front of the MAR in each health clinic. The next step was to organize the MAR with tabs for daily medications, diabetes medications, per diem medications, self-carry medications, and discontinued medication orders. These SWI outlined the chronological steps in the process to avoid an error. The steps included (1) Open MAR, (2) Ask student name and birth date, (3) Unlock med cabinet and find med, (4) Verify 5 Rights, (5) Compare medication to medication record 3 times, (6) Give medication, (7) Write it! Document date, time given, (8) Count and document remaining pills, (9) Sign MAR, and (10) Close MAR (Akron Children’s Hospital, 2013). The SWI were printed as color 8½ by 11 sheets, laminated, and posted on the medication cabinets in the 26 school health clinics.
310 NASN School Nurse | November 2013
Control The school nurse conducts a monthly reconciliation by reviewing medication orders against the MAR. If there are discrepancies, the school nurse records a medication documentation error report and provides re-education to the UAP. On a monthly basis, data are analyzed,
evaluated, and reviewed with the UAP, nurse manager, and nursing director. Next, the team created a future state value stream map depicting the envisioned process (see Figure 3). To achieve the targeted state, the school RN met with all UAP to discuss SWI to prevent documentation errors.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
Figure 4. Documentation Errors
Data were collected monthly to track and trend the documentation error rate following implementation of SWI. The UAP knew that the medication records would be closely observed at least once a month.
Results Following implementation of the SWI in September 2011, the UAP developed an increased awareness of the importance of an accurate medication count with documentation required after each dose is given to the student. For example, the UAP caught pill count errors including errors attributable to theft, errors by staff temporarily assigned to work in the clinic, and teachers or staff giving the medication after clinic hours. From September 2011 through June 2012, the clinics realized an 18% decrease in documentation errors. For a total of 16,836 medications administered during that timeframe, there was a total of 16 documentation errors (see Figure 4). Considering the large total number of medications administered in the school clinics, the error reports decreased dramatically.
Implications for School Nursing The A3 process was successful for several reasons. First, problem solving was a shared experience between the school nurse and the UAP. Collaboratively, point of care staff
identified barriers and solutions to decrease medication documentation errors to improve student safety. Second, all stakeholders actively looked for ways to improve student safety by reducing medication administration documentation errors. Medication error rates declined overall with increased monitoring and audits of the process. Licensed and unlicensed staff temporarily assigned to the clinic accounted for three of the documentation errors. This leads to the potential for more detailed review of SWI with temporarily assigned staff and teachers. Now that a process is in place, the challenge will be to sustain a continued decrease in medication administration documentation errors. The SWI also allowed for prompt identification of medication theft from the clinic after school clinic hours. The DMAIC process can be replicated by any personnel involved in medication administration in the school setting to enhance safety practices.
Conclusion This project aligns with recommendation two of the Institute of Medicine’s (2010) The Future of Nursing: Leading Change, Advancing Health, which calls for nurses to engage in quality improvement efforts. The author had the opportunity to learn a new process improvement methodology with teaching and coaching from a qualified nurse employed by the health care organization. The diffusion of the successful practice also aligns with this recommendation. School nurses can ensure safe health care in the school setting by learning and implementing quality improvement methodologies. ■
Acknowledgments The author wishes to thank Sheryl Valentine, MBA, BSN, RN, MBOE, Center for Operations Excellence, Akron Children’s Hospital, for assistance with the A3 project; Cheryl Christ-Libertin, DNP, CPNP-PC, Center for Professional
Practice, Akron Children’s Hospital, for assistance with manuscript preparation; and Michele Wilmoth, MSN, RN, manager of School Health Services, Akron Children’s Hospital, for support with the A3 project.
References Akron Children’s Hospital. (2013). School health services standard work instructions medication administration. Akron, OH: Akron Children’s Hospital. Center for Operations Excellence. (2012). A3 training manual. Akron, OH: Akron Children’s Hospital. Farris, K. B., McCarthy, A. M., Kelly, M. W., Clay, D., & Gross, J. N. (2003). Issues of medication administration and control in Iowa schools. Journal of School Health, 73(9), 331-337. Ficca, M., & Welk, D. (2006). Medication administration practices in Pennsylvania schools. The Journal of School Nursing, 22(3), 148-155. Ghosh, M. (2012). A3 process: A pragmatic problem-solving technique for process improvement in health care. Journal of Health Management, 14(1), 1-11. Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jimmerson, C. (2007). A3 problem solving for healthcare. New York, NY: Productivity Press. Price, J. H., Dake, J. A., Murnan, J., & Telljohann, S. K. (2003). Elementary school secretaries' experiences and perceptions of administering prescription medication. Journal of School Health, 73(10), 373-379. Richmond, S. L. (2011). Medication error prevention in the school setting. NASN School Nurse, 9, 305-308.
Laurel A. Celik, BSN, RN, NCSN School Health RN District Supervisor School Health Services Akron Children’s Hospital Akron, OH Laurel is the school health RN district supervisor for 23 health aides in an urban school district.
Downloaded from nas.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on March 7, 2015
November 2013 | NASN School Nurse 311
