The purpose of this Clinical Nurse Leader (CNL)-led evidence-based practice project was to implement a process improvement strategy to create transparency in unit-specific communication processes and promote trust in the leadership team of an inpatient nursing unit by utilizing a Gemba board for information gathering and distribution. Prior to the intervention, unit staff voiced their ideas and concerns to coworkers or leaders regularly, yet staff saw little follow through or received no feedback on process change updates. The Gemba board was introduced, not only to share clinical and quality outcome data, but to provide opportunities for staff, from all disciplines, to suggest unit-specific process changes of any significance with a guaranteed response from leadership.
Background/Significance:
High-performing health care institutions must look at the effects that staff burnout and disengagement have on the patient experience. The Institute for Healthcare Improvement encourages the application of the Quadruple Aim, improving the experiences of healthcare workers who provide patient care (Sikka, Morath, & Leape, 2015). Gemba boards address staff engagement and empower the voice of all staff within the organization. Staff are more likely to be engaged and positive about their work environment, thereby promoting best outcomes for patients when they feel supported, empowered, and respected by their leadership (Kang, Lee, & Choi, 2017; Feeley, 2017).
Gemba boards are a Lean strategy used to bring people together to analyze and share work that is being performed. The term “Gemba” is Japanese for workplace, translating to “the real place where work is done” (Bourgault, Upvall & Graham, 2018). Gemba boards are gaining traction in healthcare facilities as meaningful places to share quality indicators and facilitate practice change. Previous studies determined that Gemba boards are effective in facilitating staff, leadership, and interdisciplinary communication, encouraging transparency of outcome data, solicitation of staff ideas and feedback, and dissemination of practice changes (Bourgault, et al., 2018). Nursing engagement directly correlates with patient safety, quality and patient experience outcomes, and staff satisfaction/retention (Dempsey & Reilly, 2016).
Intervention:
This evidence-based project was guided by the Iowa Model-Revised (University of Iowa Hospitals and Clinics, 2015), developed and implemented by two CNLs on an inpatient pediatric nursing unit in July 2018. The Gemba board was introduced after a unit-based staff satisfaction survey identified a decrease in staff satisfaction regarding: (1) lack of follow through by leadership on ideas for unit-specific process changes, (2) need for improved communication, and (3) a desire to be more involved in decision making. The CNLs conducted a comprehensive review of current literature to evaluate evidence-based initiatives to facilitate staff engagement and process changes. The literature supported the emerging presence of Gemba boards in healthcare; the CNLs worked with a hospital-based Process Improvement Specialist to implement and evaluate the effects of the first nursing unit-based Gemba board within the medical center.
The Gemba board was located in the staff breakroom, utilized by staff from all disciplines. Quality outcome data was posted and updated monthly. This included information on hospital-acquired condition (HAC) rates, HAC bundle compliance rates, patient and caregiver feedback gathered through leadership rounding, and caregiver feedback gathered from discharge phone calls.
“Idea cards” were also posted on the Gemba board with space for any staff member to record an idea, suggestion for change, or problem. Each idea card asked for the idea, suggestion, or problem, the date, and the person’s name, although anonymity was an option. The CNLs assign each idea card to an appropriate staff member or leader. Progress updates were communicated on the idea card for all to see how each idea was being addressed. Completed idea cards were kept on a keyring on the Gemba board. Each month, Gemba project updates were included in a newsletter and sent to all unit staff.
Results:
The Gemba board continues as an ongoing evidence-based process improvement initiative on a 26-bed nursing unit. Process changes implemented since the Gemba board began have ranged in complexity and significance. An idea that was easily implemented, with the potential for a significant impact on patient safety, was to place the code blue call number on each unit telephone. The CNL assigned this task to a staff nurse who was also the unit representative on the hospital-wide patient safety committee. The staff nurse collaborated with an infection control nurse to find an appropriate label or sticker to place on the telephones. This idea was completed in four days. Another simple, but potentially high impact idea, was to develop an education handout to inform patients’ caregivers of the new diaper-changing processes for patients with a central venous line (CVL). The CNLs took on this project and worked with the hematology and quality departments to explore best options.
A highly complex and impactful suggestion was to begin a daily safety huddle to discuss patient safety concerns at the beginning of each shift. This idea was assigned to the CNLs. The CNLs have formed a multidisciplinary team including a Speech Therapist, the unit’s Assistant Director, the Director of Nursing Research and Evidence-Based Practice, and the hospital’s Safety Program Education Coordinator. The team evaluated literature and brainstormed the best evidence to implement a daily safety huddle that will reach as many staff as possible and address as many needs as possible.
Implications for Nursing Practice:
Within three months, the Gemba board has shown to be a useful tool for healthcare leaders to share quality and clinical outcome data with all unit staff. The Gemba board also empowered staff at all levels to have an impactful voice within the unit. Unit leadership was held accountable for each idea, suggestion, and problem that was presented on the Gemba board. Staff received timely updates and explanations for decisions. The Gemba board’s promotion of trust in leadership and transparency in decision making processes has the potential to be highly impactful in nursing units across healthcare.
Goals for advancement of the Gemba board on this pediatric nursing unit included: (1) maintaining utilization of idea cards, (2) reassessing staff satisfaction levels, and (3) possibly implementing a Gemba board open to the general public on the nursing unit that would include clinical outcome data and idea cards for patients, visitors, and caregivers to utilize.
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