352 - Improving Competency Documentation Process Using Lean Six Sigma
Clinical Issue: The Operating Room (OR) orientation is complex due to the length of time in orientation and amount of documentation required to demonstrate individual competency. This process includes multiple clinical preceptors. This leads to inconsistency, inaccurate or missing completion of documentation. Description of Team: The team consisted Registered Nurse (RN) Educator, project sponsor, subject matter expert, and core team members. Preparation and Planning: The OR RN Educator developed a project charter, which defines the problem, scope, and timeline for the project. Clinical preceptors completed a survey to determine the “voice of the customer”.
Assessment: The team met to analyze the root causes of why the current state is not working. The team determined the critical root causes, which included amount of paperwork, inconsistent preceptors, and unclear places to document. Baseline data showed an 80% completion rate for competency documentation. The goal is 100% completion of competency documentation. The team created a process map to show where the bottlenecks occurred. The team brainstormed possibilities of using the learning management system (LMS) for competency documentation. Implementation: The RN Educator selected 12 basic competency checklists to build into the electronic system. The clinical preceptors received education related to the checklist documentation in the LMS. During a six-month timeframe, the new staff and preceptors completed a pilot study. The pilot showed 47% completion. This resulted in a gap analysis identifying for more preceptor education. There were LMS access issue concerns for validators and checklist creation methodology. Staff members completed another pilot. Outcome: The second pilot study showed improvement in the process and resulted in a 100% completion rate. The control plan for this project includes continuous monitoring and an action plan in place if the completion rate drops below 100%. The nurse educator presented this project for Lean Six Sigma Green Belt Certification in August 2019. Implications for Perioperative Nursing: Nurses do not think in process improvement mode. Lean Six Sigma is about asking the questions and identifying the problems. This methodology can provide perioperative nurses with systematic steps to improve and sustain complex processes.