Case Study: 5S Event, Ward 18, Orthopaedics, NinewellsHospital, NHS Tayside.

What was the problem?

Ward 18, NinewellsHospital is an extremely busy, 30 bed, Orthopaedic Trauma Ward. Main issues identified by the staff within the ward were:

  • ‘Things’ do not have a place, staff are unsure about where to store items, where items are kept, unclear of their roles and responsibilities in relation to this.
  • Time wasting was of great concern to staff within the ward. Various tasks were being held up due to non-replacement of finished items. This is causing delays for the next member of staff in carrying out their tasks due to lack of equipment or supplies. In general, items are not being replaced when finished, there are issues with re-stocking and ordering of items
  • Interruptions to staff and patients are an issue for example telephones constantly ringing throughout the ward, queries at inappropriate and inconvenient times. Buzzers going when staff are in the middle of another task, interruptions during meal times, patient rest times and drug rounds by other healthcare professionals and visitors. Staff members being disturbed from the task in hand as items cannot be found.
  • Inadequate and often broken storage facilities throughout the ward.
  • Perceived lack of space within the ward area. When in fact the issue was around the amount of clutter, unnecessary and unused items within the ward.
  • Lack of equipment and difficulties sourcing equipment.
  • Duplication of tasks due to poor communication and reporting.
  • Heavy reliance on the Healthcare Assistant for multiple tasks in particular with the supplies and ordering of stock for the ward.

What improvement tools used?

A 5S Event was held from 8th – 10th August 2007. This tool, which forms part of lean methodology looks to improve visibility and make value flow. It consists of 5 steps: Sort, Set in Order, Sweep and Shine, Standardise and most importantly Sustain. 5S helps create and maintain a clean, safe, less wasteful, efficient and high performing workplace.

A multidisciplinary team consisting of representation from the ward nursing staff, (Senior charge Nurse, Senior Staff Nurse, Nursing Auxiliary and Healthcare Assistant), Domestic, Early Supported Discharge Co-ordinator, Pharmacy, Portering, Supplies, NHS Tayside Modernisation Team, Scottish Executive were freed from their work commitments and were facilitated through the event by Ross International.

Having been introduced to the principles of 5s the group split into 3 teams: Audit Team, The Process Team and The Red Tag Team. Specific areas were identified for the teams to work within. These areas included the Treatment Room, Disposal Room, Store Rooms, The Airlock and the large bathroom. The teams were tasked with the following in each area:

  • The Audit Team conducted environmental audits of the identified areas or trouble ‘hotspots’. The audits reflected the 5S process by looking at each step and assessing the environment accordingly on a scale of 0 to 4, (4 being likened to world class standard). Only the first 3 steps in the process were completed initially, with a view to completing all 5 steps of the 5S Audit once the required changes have been implemented.
  • The Process Team carried out mapping exercises of key tasks and processes for areas of main concern to the team. These included the Drug Trolley Round, Staff Nurse and Nursing Auxiliary duties with the aim of identifying the non-value adding steps in these processes, establishing where and when interruptions and time wasting occurs.
  • The Red Tag Team were to visit each identified area with a view to ‘red tagging’ all items that were to be condemned, returned to other areas, to be stored in a temporary location until the existing area could be ‘sorted’ and ‘set in order’. There were additional items required for use by other healthcare professionals that were to be stored in a new designated location.

During the sorting phase key processes were identified for improvement. These involved patient rest times, meal times, visiting times and also interruptions to processes and patients during these busy times. During this activity there were also opportunities to speak to staff and patients about their experiences.

A set of Management and Team Goals were developed:

Management Goals:

  • More time for staff to carry out their clinical duties
  • A place for everything, everything in its place
  • Safety and infection control issues to be addressed
  • Areas easy to keep clean
  • Reduce paperwork
  • Maintain tidiness
  • Staff feeling supported by management

Team Goals:

  • A place for everything, everything in its place
  • Less Stress
  • Less running about
  • Easier access to supplies and stores
  • Overall better working environment
  • More time for handovers

An action plan has being developed to address the longer-term issues. These issues include outstanding Estates work, education of staff within the ward and the wider multidisciplinary team, the implementation of a telephone answering machine, reduced visiting times and protected meal times, Physiotherapy updates, large update to be given at the start of each week with smaller updates throughout the week. Timescales and identification of persons to take forward actions are identified within the action plan.

What is the situation now?

Education of staff with regards to changes has commenced / Completion of ‘sorting’ and ‘setting in order’ of treatment room, airlock, disposal room, store rooms & doctor’s room.
New processes implemented for supplies and ordering of stock. For minimisation of waste and surplus stock. New process has been tested following the event. / Within the Treatment Room ease of access has been created for required items. Frequently used items and heavy items are located at a convenient height, no drawers are overflowing with items, parts used together grouped together in the same drawer. A system put in place to reduce the risk of out of date and obsolete stock.
Store cupboard within the ward has been reorganised. The Physiotherapy Equipment has been relocated to a different store cupboard at the ward entrance. / Temporary shelving and organisation of cupboard at end of all the bays to allow for ‘self-sufficient’ bay set up.
New improved signage throughout the ward area / Labelling of all storage facilities within rooms and ward area.
Relocation of nurses mail and lockers to designated room (previously store cupboard) / Shadowing/observation processes of staff members, has allowed appreciation of differing staff grades around each other’s duties and workloads.
Time and monetary savings following 5S event and new lean processes implemented. Having just the right amount of stock and supplies at any one time. Continuous monitoring of changes to ordering of supplies is in place. / Additional time and effort has been put in by SCN an Nursing Auxiliary to complete the setting in order and to result in sustainability of the changes that have been put into place over the initial 3 days.
Long-term Action Plan developed

Ward 18, Before and After Photos

A number of photographs were taken of the areas involved in the process at the start of the event. Further photographs were taken during the three days as the improvements were taking place. A selection of these are illustrated:

The pictures below show one of the storage cupboards within the ward, which was used for storing surplus supplies.

During the event the storage cupboard was cleared of any surplus stock. The room was then transformed into an area where the nursing staff could secure their personal belongings. In addition a place was created to situate the mail trays for the nurses. A notice board will be placed on one of the walls within this room to display general information and educational events relevant to the nursing staff.

This photograph shows the store cupboard with the removal of the surplus stock, with lockers to secure belongings and the notice board for display of information.

The following before and after photographs illustrate the ‘air locker’ area within the ward, which is utilised by the ward assistant. The mail trays were removed and placed in the newly organised room for the nurses, removal of excess clutter within this area permitted a clear view from the window.

These photographs were taken within the Treatment Room area within the ward. The work top areas were ‘sorted’ and ‘set in order’ to facilitate the efficient preparation of materials for clinical procedures.

Before:

This photo shows the organised work area within the treatment room, with items clearly labelled, in the location that they should be stored, ‘A place for everything, everything in its place’.

Shown below are photos from the main store cupboard within the ward, previously this cupboard was used by the Physiotherapists for storage of equipment in addition to any other equipment and unused item within the ward. During the event the Physiotherapy equipment was relocated to a store area at the entrance to the ward. This allowed the cupboard to be reorganised to store essential items only. The cupboard has since undergone further transformation, with removal and usage of the stock allowing further sorting to take place.

Before: During the event:

The sluice area was set in order, with clearly marked areas to house equipment. Cupboards and shelves were labelled to show where the supplies should be stored.

Before:

After marking and labelling has taken place:

Measurable Outcomes

5S Environmental Audits

Weekly environmental audits will be conducted to ensure the sustainability of improvements that have been implemented throughout the ward

Overstock Financial Savings

The supply of material/equipment was reorganised to move from a ‘push’ system, where the ward was given what somebody else thought they needed to a ‘pull’ system where the ward will now request only the quantities they need. In preparation for this to happen, current stock levels were reviewed and overstock was returned to the suppliers. The following table details the items returned and the financial savings associated:

Quantity / Description /
Cost (£)
50 / Sterile Scissors / 36
240 / Gauze Swabs / 18
50 / Non-woven swabs / 5.28
100 / Bio Valves
2 / Ultrasound Gel / 10
50 / Charcoal Swabs / 5
120 / Dressing and Forceps Pack
36 / Gallipots / 29.16
65 / Hand rub / 63.05
10 / Luerlock syringes / 58
1 / Baby Powder / 6
3 / Diprobase Cream / 12
4 / Braun Moisturiser / 20
21 / Fluid bottles
31 / Humidifying Liquid
1 / Hibiscrub / 1.60
1 box / Small Knee / 33.49
1 box / Medium thigh / 42.30
1 box / Large thigh / 42.30
4 boxes / 1000ml handwash / 81.16
2 boxes / Female urinals / 26.54
1 box / bowls / 17.79
85 / 3 Way Tap / 96.88
1 box / Normal Saline
52 / Giving Sets / 60.84
9 / Oral Hygiene Sets / 44.46
26 / Resp Flow Sets / 42.77
93 / Orange Needles / 1.55
108 / Blue Needles / 1.55
173 / Green Needles / 3.10
92 / Green Butterfly / 23.12
195 / Vacutainer / 13.16
87 / Blue Butterfly / 23.12
13 packs / Medication cups / 13.00
19 / Sample bottles R / 18.20
95 / Sample bottles W / -
66 / Sample bottles B / -
21 / Luer Lock 50ml / 5.00
20 / Nebuliser / 15.00
22.96 / Vacutainer / 141.30
Obsolete Stock
43 / Wound Probes
12 / Mercury Thermometer
2 / Hand Towel Holders
Overstock / In excess of £1500
Pharmacy / £250 (during 5S)
£750 (preceding 5S Event)
TOTAL / £2500

The following photographs are from the Treatment Room showing the new structure that has been created. Frequently used items and heavy items are located at a convenient height, no drawers are overflowing with items, parts used together grouped together in the same drawer. A system put in place to reduce the risk of out of date and obsolete stock.

Ward 18, Treatment Room Before Stock Levels Reviewed:

Ward 18, Treatment Room After Stock Levels Reviewed:

Benefits

What are the benefits to patients?
  • More time with nursing staff
  • Less time waiting for care and attention.
  • Quicker bed changes with items being close to hand
  • Less chance of interruptions to nursing staff whilst trying to deal with their patient (mainly due to the bay being self-sufficient with supplies and nurse not having to travel out of the bay)
  • Less stressed staff with a positive affect on patient care
/ What are the benefits to staff?
  • Less stress
  • Less running about
  • Less physical hard work due to more efficient organisation
  • Easier access to supply stores
  • Stock organised the way staff want it
  • More handover time
  • Ward prepped for next shift starting
  • Overall better working environment
  • Appreciation of each others roles and responsibilities

WHAT ARE THE BENEFITS TO THE ORGANISATION?

  • Reduction in costs/ financial savings
  • Anticipated reduction in number of complaints
  • Easier recruitment within the ward/ better staff retention/less staff sickness
  • Efficient Supplies Processes
  • Improved team working amongst multi-disciplines / more productive environment

WHAT ARE THE SAFETY BENEFITS?

  • Less risk of injury due to manual handling issues and dropping hazards
  • Efficient patient care due to ease of access to equipment
  • Everything is labelled minimising potential for error
  • Reduced risk of drug incidents
  • Better infection control as easier access for cleaning

KEY SUCCESS FACTORS

  • Involvement of staff who know the process inside out
  • Good team working
  • Enthusiasm and willingness to pursue and achieve harder goal
  • Senior Management support gave the team the power to push harder and ensure the

sustainability of the changes

WHAT WOULD WE DO DIFFERENTLY NEXT TIME?

  • Allow more time to plan the event
  • Ensure support is available from other departments
  • Improve communication about requirements to the team prior to the event
  • Assessment of suitable time period for the event i.e. weekend working

Further Information available from:
Mrs Joan Robertson
Senior Charge Nurse
Ward 18, NinewellsHospital
/
Ms Wendy Neeson
Modernisation & Development Consultant
NHS Tayside

September 2007