HOME CARE Make your daily routine “amazing:” and increase care capability Most of us are familiar with the CBS show The Amazing Race, which has just ended its 21st season. The show is designed around teams that are given nearly impossible challenges to be completed during their worldwide race. At the start, they are given a map and a specific time frame to complete their race. All the while, they are expected to dodge surprise obstacles. Sound familiar? The typical home care professional is given assignments for the day, which include preparing supplies, planning their routes, providing care, being a great listener, assessing risks, completing documentation, and maybe even doing a little light housekeeping and making some tea. Through all that, they must use their skills, and try to be finished by 4:30 pm. The demand for home care services is growing daily, with many “home first” strategies being applied nationally. These strategies are freeing up hospitals to improve patient flow, but we have to ensure that local home care programs have the capacity to deal with the increased demand. Working more efficiently Let’s start by identifying what non-value-added activities look like. In “Lean,” we look for the eight wastes. They are captured in the acronym DOWNTIME. Defects: Work or services that are not completed correctly the first time. Example: having the wrong address or date for a client visit. Overproduction: Doing more than what is required to complete the task. Example: doing a dressing change and also helping the client take a bath or get dressed. Waiting: Idle time when material, information, people or equipment is waiting. Example: arriving on-site but the client has not arrived or is not ready for your visit. Non-utilized talent: Not utilizing all the skills of the employees. Example: having a nurse doing the scheduling for home care client visits. Transportation: Unnecessarily moving equipment, supplies or information from place to place. Example: having to haul equipment from site to site when it may not be needed. Inventory: Having more material, supplies, equipment or parts on hand than needed. Oversupply requires extra space and the purchase of supplies that never get used or expire, and wastes resources that could be better spent for value-added activities. Example: bringing in extra supplies for clients but not using or needing them, causing overfull shelves or travel totes. Motion: Unnecessary movement by employees to complete an activity, including driving. Example: driving a zigzag pattern to get to all the day’s clients. Extra processing: Adding more work than is required by the client. Example: packing up every possible combination of dressing and hauling it to the client’s site. One of the realities for home care staff is that they may be the only contact the client sees that day, or maybe even that week or month. Couple this with the caring and compassion of a health care provider and you know what may happen—yes, they will do the little extras that the client asks for or needs completed. They will help with some cleaning, pull a box down from a high shelf and, most commonly, spend some extra time simply talking with the client. The hard question that is most frequently asked is, “How do I prevent the extra tasks so I can get to my next client?” Unfortunately, this becomes the mantra for every home care worker who walks through a client’s door. What does the client value? The answer falls within understanding value-add and non-valueadd. We have already defined the eight wastes, which of course represent the non-value-add. Value-add is defined in health care as face time or anything that adds value from the client’s perspective. I am very positive that if we asked the little grey-haired lady with the pressure ulcer whose dressing you changed if she values the time you have spent with her, the answer would be a resounding yes. When she looks at you with those weathered blue eyes and asks you to stay for a tea, how can you possibly say no? The right answer should always be, “Yes, I will stay.” We work in an industry that is defined by the word ‘care’: home care, health care, primary care. This is your identity: to be there, to deliver care and to show compassion. This may seem contradictory. In one paragraph I discuss waste and the challenges of increased demand, and then in the next paragraph I am saying you should have a cup of tea with each client. Let me clarify. What I am saying is that we need to define value and deliver it, and define waste and remove it. By doing this, we can not only increase the number of clients we see but also have the time to deliver the care they need! Reducing waste Let’s look at some opportunities to reduce non-value-added activities. We might recognize that we spend too much time driving from location to location. This is considered motion and transportation waste. As new clients are constantly being added to the day, we need to ask a few questions: Do we have a way to identify the best home care worker to visit that client? Do we just fit a new client into an open slot regardless of where they are located in relation to the other clients? Do we juggle the day to geographically set the schedule to best accommodate the drive but then waste time calling clients to change their time? The struggle is with identifying the right answer to meet everyone’s needs. There is a theory that fits this dilemma, called the “paradox of choice.” The paradox of choice means that when faced with one of two choices, we will typically make the best decision; however, if we are faced with more than two choices, we will typically become paralyzed by our need to make a decision and will not make the best choice. Think of your favourite ice cream flavour; now put yourself in front of a hundred flavours. Does this make your initial choice still seem like the right one? The next piece of the puzzle is identifying what is important to your organization, based on client feedback and the overall organizational need. The answers are usually multi-levelled. We want to have client safety, timely access, client satisfaction, fiscal responsibility, etc. (the paradox of choice). This is where the problem starts; it’s a lack of clarity for the home care organization. There is a business slogan that is very appropriate: clarity reduces resistance. For example, if the organization says its reason for being in business is to maximize the time spent with each client, then the behaviours and structure would have to match that statement. This could quickly answer the question of which home care nurse takes on the new client; it would be the one that is closest to that new client. The organization would adjust the travel and appointment schedule accordingly to reduce travel time and increase client time. Not that we want home care to turn into the dreaded cable guy, who says he will be there between nine and five on Tuesday; instead, we should emulate the reliability of the UPS driver: “I will be there before 9 am” to give an outside limit of when you will be there. Imagine the precision and clarity of purpose that UPS has to have in order to deliver a package picked up in Vancouver at 5 pm one day and have it at the receiving spot in Halifax before 9 am the next day. A problem-solving tool As health care providers, we get caught in our paradigms of how care must be delivered. In home care, we tend to think that once someone has been assigned a client, they have to see them through to the end without substitution. This causes a prohibitive factor and would cause the caregivers to do more non-value-added work than necessary to maintain this continuity. As the non-value-added travel increases, it reduces the number of clients who can be seen. So which is the bigger issue: not having continuity or not being able to service clients? A tool called Force Field Analysis can help identify and solve these issues. It was created in the 1940s by Kurt Lewin, who originally used the tool in his work as a social psychologist. Force Field Analysis is used in many organizations today to help people understand the organization’s identity and how to change it. The tool is designed to understand what is driving change, and what is preventing change from happening. Once you and your team understand this, then you can focus on what is required. How to use the tool To carry out a Force Field Analysis, copy the template shown in Figure 1 to a flip chart or whiteboard. • In the middle, identify the macro change initiative. • On the left-hand side, list the drivers of change. • On the right-hand side, list the drivers against change. Brainstorming and divergent thinking tools can help the team achieve a comprehensive list. Scoring Create a scoring criteria. For example, you could have a range from 1 for weak (meaning it has very little impact on the client and organization) to 5 for strong (meaning the client will be greatly impacted and all staff will feel the change). If you are doing this on a flip chart or whiteboard, you can draw the arrow larger or smaller to represent either increased or reduced impact. Total up the values for each column and note if the restraining forces are greater than the driving forces. If they are, then your team would move to the analysis phase. Analysis One of two decisions can now be made: 1. Decide if it is appropriate to move forward with the change at this time. 2. If you decide to move forward with the change, what items in the negative forces will you focus on improving? In your analysis, take this stepwise approach: 1. Review each item in the Forces against change column, and ask what mitigating actions you can put in place to reduce this impact. 2. Put the new ideas in the Forces for change column, or update the items already in the column. 3. Complete this for all identified items on both sides of the analysis. 4. Recalculate the totals. Have the mitigation ideas changed the ratio to show the change will make a positive shift? 5. If yes, then begin your improvement initiative. 6. If no, then you need to see if there is more that can be done, or re-evaluate whether making the change would be in the organization’s best interest. A Force Field Analysis and action plan should take about half a day to complete with the team. Conclusion In review, the steps to improve home care access would be: Create clarity of purpose—what is the number one, most important thing to us? Use the Force Field Analysis tool to identify the driving and restraining forces. Brainstorm actions to reduce the restraining forces. Implement your action plan to achieve the improved state. These four points may seem simple but as we all know, changing our paradigms about care delivery is not easy work. If you choose to follow these four steps, you will improve work–life balance for workers and increase satisfaction levels for clients. Until next time, keep improving Dale Schattenkirk is the president/CEO of Learning To See Consulting. Dale is a certified Lean Six Sigma Black Belt, an International Organization for Standardization auditor and a certified human resources professional. What is Lean? Lean thinking is the belief that there is a simpler, better way through a continuous drive to identify and eliminate waste, or inefficiencies and errors, in our day-to-day work. It’s about making our work environments efficient and effective, so we can provide higher quality of services to our customers and clients. Lean improves safety, quality, costs, efficiencies and service delivery. In health care, it helps to release time for direct resident, patient or client care and creates time for quality improvement to be part of everyday routine activity. It’s is not about making people work harder, but about removing non-value-added activities or waste out of how environments are designed to function, so that people work more efficiently. Waste is anything that does not add value from the customer’s point of view, whether it is an internal or external customer. Value to a customer is what the customer sees as being important or that can better their quality of life.