AS ORGANIZATIONS and providers look to do more with less and finances become increasingly important, eliminating inefficient practices is essential in healthcare. Higher performing hospitals seek to improve efficiency in healthcare delivery, and efficient care includes the appropriate utilization of equipment, supplies, ideas, and energy. Time is a resource, and nurses have little to spare. The opportunity cost, or the “next-highest-valued alternative use of [a] resource,” of wasted time on a nursing unit is the hourly wage of the nurses in addition to the value of time otherwise spent caring for patients.1
Evaluating and changing processes is key to decreasing inefficient practices. The National Academy of Medicine recommends avoiding inefficiency as one of the primary aims to improve care delivery.2 Similarly, the National Quality Forum and the Agency for Healthcare Research and Quality have both indicated that inefficiency and waste must be eliminated to maximize value and minimize healthcare costs.3,4 This article describes one unit's success in achieving increased efficiency and nursing satisfaction through improved organization.
KentuckyOne Health Jewish Hospital is a 426-bed urban tertiary referral center. The nursing staff in the open-heart recovery room and cardiovascular intensive care unit (OHRR/CVICU) was dissatisfied and frustrated with the time spent collecting supplies and medications for patient care. One task could require the nursing staff to retrieve supplies from up to five different areas on the unit.
Supplies were located in the unit supply room and in two automated dispensing cabinets (ADCs), one in the front of the unit and the other at the back. Supplies were also stored in the hospital's central supply department two buildings away. Similarly, medications were also kept in two ADCs at the front and back of the unit. The nursing staff considered these inefficiencies to be a barrier to providing the best possible care and communicated this to their unit-based council (UBC).
Two clinical nurses active in the UBC shared the staff's frustrations with their unit manager, who encouraged and empowered the nurses to make a change. She recommended they reach out to a clinical nurse specialist, who suggested the FOCUS-PDSA (find, organize, clarify, understand, select-plan, do, study, act) quality improvement model to guide the project (see The FOCUS-PDSA quality improvement model).5 The model helped to ensure the team included any steps that may have impacted project outcomes. Additionally, the clinical nurses planned to use the project for a nursing professional development program, which required measurable outcomes.
Developing the team
After identifying supply efficiency as an area for improvement, a team of core stakeholders was established for input. These included unit staff and leadership, supply and distribution staff and leadership, pharmacists, and a clinical nurse specialist. The clinical nursing team leaders scheduled meetings with each stakeholder to collaborate on ideas, protocols, and procedures vital to the success of the project.
Knowledge and action
Although the nursing staff regularly commented on the time taken to gather supplies and medications, more objective data were required. A small convenience sampling on the length of time to gather supplies was obtained over several shifts at the beginning of the project. The clinical nurse team leaders used a stopwatch to time the nurses as they collected supplies.
Additionally, perspective from the nurses and ancillary staff was gathered using a survey with questions based on a five-point Likert scale and open-ended responses. It was handed out personally, placed in unit mail files, and distributed at UBC meetings. Staff was incentivized with candy for returning a completed copy.
The survey provided suggestions for improvement and increased engagement for other direct care nursing staff and unlicensed assistive personnel. Supply and medication usage reports were obtained and analyzed to identify frequently used items. The project examined items not stocked, requiring nurses to make a trip to the central supply department, as well as those regularly stocked items that were seldom used.
The OHRR/CVICU is shaped like an “L” with one stockroom in the middle of the unit and ADCs for supplies and medication toward the front and back. Based on survey feedback, the stockroom was reorganized to group frequently used supplies together to make it more user-friendly. The ADCs for supplies were reorganized so that items used for the same task were kept together. This helped limit the need to travel to multiple storage areas or open multiple doors to find supplies for a single task. Supplies that were no longer in use were removed, allowing additional space for items that required frequent trips to the central supply department.
Having two ADCs for medication also caused inefficiencies. Daily routine medications were originally stored in an ADC in the back of the unit, and emergency medications were kept in the other at the front. Because most patients were located in the front half of the unit, the nursing staff regularly had to leave their patients' vicinity to gather any routine drugs. Similarly, nurses in the back of the unit had to run to the front for emergency medication. Following careful collaboration with pharmacy stakeholders, the medication systems were redesigned to be identical, containing both daily routine medications and emergency drugs.
Although the unit manager supported the project, the clinical project leaders discovered that collaboration was necessary for completion in such a busy unit, as changes to the ADCs required coordination with both the supply and pharmacy departments. To build support and obtain buy-in, staff was educated on the project's goals and upcoming changes beforehand via email, unit posters, and individual staff-development programs. Supply and medication reorganization took time, though. Supply changes took place over several day shifts when the census was low, and the medication ADCs were each reorganized on a Sunday night while the medication needs of the unit were at their lowest. Project managers were paid extra to come in on these days to complete the reorganization.
Once the reorganization was complete, staff surveys were distributed again and data on supply gathering times were collected. Satisfaction rates were higher regarding the organization of both supplies (2.22 preorganization; 3.82 postorganization) and medications (2.47 preorganization; 4.19 postorganization) on the unit, with respective P values of .00. Additionally, staff Likert ratings indicated decreased levels of agreement with the statements, “It takes too long to obtain medications” (3.71 preorganization; 2.88 postorganization, for a P value of .05), and “It takes too long to obtain supplies” (3.94 preorganization; 3.0 postorganization, for a P value of .02) (see Significant staff survey results).
Notably, the average reported number of visits to multiple ADCs for medications decreased from 4 visits per shift preorganization to 0.47 postorganization, with a P value of .00. Similarly, the length of time to obtain supplies per trip decreased from 2.7 minutes preorganization to 0.8 minutes postorganization (see Length of time spent gathering supplies). Based on the average number of trips required, the reorganization saved the unit approximately 20 minutes per nurse during a shift.
Opportunity cost takes into account the potential uses of time otherwise spent searching for supplies, such as additional patient care. The nursing staff identified a significant opportunity cost with this project. By multiplying the average time saved (20 minutes) by the average number of nurses on the unit per day (16 RNs), the project saved approximately 5.3 hours per day. If the nursing staff no longer had to work these hours, their hourly wage could impact the cost of searching for supplies. By factoring in the average hourly wage of the nursing staff, the daily savings would be approximately $151.95 for the unit, or up to $55,461 annually.1
As the success of the project was shared internally, other units also expressed interest in decreasing the time spent gathering supplies. To standardize the changes, the OHRR/CVICU shared information with other units to help with any potential barriers and pitfalls. Although it took dedicated clinical nurses and a team of willing stakeholders to make the project successful, it improved both unit efficiency and staff satisfaction. It may be a contributing factor to increased patient safety and satisfaction as well, as decreasing the time spent on one routine task helps to increase the amount of time the staff is able to spend on more important nursing care.6