Fixing our laundry woes: this facility took a CQI approach to this troublesome area, and it worked.

Life Care Center of Hilo, part of the Life Care Centers of America, is located on the Big Island of Hawaii. Our long-term care facility has 252 beds, including two secured dementia units.

Prior to 1995, our staff had not received any formal continuous quality improvement training. They had no idea what "CQI," "TQM" or "PI" meant. Our performance improvement "journey" started in July 1995 as a voluntary "brown bag" affair. Staff were asked to come on their own time to participate in the learning process. Additional sessions were held in the Fall of 1995 and continued in 1996 and 1997. This article chronicles the results of our first official CQI team to emerge from this training.

The team was called "Laundry Shut-Down." The steering committee, composed of department heads and administration, had been wrestling with recurring laundry machine breakdowns, increased disposables usage and increasing costs of contracted laundry services. These three main issues added up to thousands of dollars that could be better utilized elsewhere. Therefore, the laundry process was chosen as the focus for the first official team.

The steering committee developed the mission statement, appointed initial team members and assigned a facilitator. The team consisted of ten associates representing nursing, housekeeping, laundry and management. All three shifts were represented.

Our mission statement was simple: "Shut down the laundry process for at least four hours per day." Our executive director, Patricia Allard, explained that long-term care laundry operations are not normally run 24 hours per day. The stress put on our machines was evidenced by frequent breakdowns, with subsequent high repair costs. Our isolation, due to geographic location, compounded the repair process. Parts for large industrial washers and dryers require shipping, and their weight alone drives up shipping costs. The wait for parts is often three or four weeks.

During the wait, disposables are used for incontinence care, as local commercial services do not accept linen soiled with body fluids. This alone can add up to thousands of dollars when caring for a census of 252 residents. Additionally, energy costs are high in the islands. Reducing operating hours would conceivably reduce both repair and energy costs.

In our initial meetings, team members reacted with fear and distrust. Comments ranged from "There is not enough linen now...how can you shut down the laundry?" to "It's nursing's fault there's not enough linen!" to "Days and PMs use all the linen and there is never any left for night shift!" to "Why are we here? Administration will do what they want anyway!"

We started each meeting by depersonalizing the mission statement. Emphasis on flow charting the process as it existed kept the team focused on system issues rather than on personalities and blame tactics. We then went on to the crucial steps in implementation.

Step 1: Management Education

At the weekly department head management meeting, the need for the team and for department representation was discussed and developed. Each department would be instrumental in providing resources to make the team successful.

Step 2: Team Education

Staff were notified of their appointment to the team. The first several team meetings proved to be a challenge, as already indicated. Participants came with preconceived ideas about management and each other, as well as the mission of the team.

The educational methods used were based on the teachings of CQI innovator J. Edwards Deming. Our development of resources for team conduct, tools, data collection and analysis was guided by the use of reference books, as well as by our facilitator. The books described team process and tool utilization. Our facilitator, a Certified Professional in Healthcare Quality (CPHQ), had prior expertise in team process, tools and data analysis.

Each meeting started with an "icebreaker" exercise, followed by a mission statement review, review of consensus on ground rules and a recap of the last meeting, with emphasis on what we wanted to achieve in the current meeting. This format kept us focused and on track.

Step 3: Understanding the Mission Statement's Intent

The directive from the steering committee seemed simple enough: Shut down the laundry operations for four hours per day as soon as possible. The team, through analysis, defined the purpose of the mission statement to be as follows: Decrease laundry operations by four hours per day to decrease machine breakdowns and facility overhead costs.

Step 4: The Journey

The mapping of the linen flow process [ILLUSTRATION FOR FIGURE 1 OMITTED] took approximately four meetings. A separate flip chart page called "the holding tank" was created to record all the problems identified along the way. From the holding tank, the team developed their cause-and-effect diagram [ILLUSTRATION FOR FIGURE 2 OMITTED].

The biggest problem the team had was staying focused on the mission statement because so many process problems were identified. The team agreed they could not fix everything at once. The team motto was "Rome was not built in a day, nor will the linen process be fixed in a day."

Data collection consisted of linen use patterns, inventory and pending purchase order requests. Additionally, outcome data were utilized correlating wound healing with linen use type.

The team then evaluated pieces of the linen flow process that team members felt would be directly affected by the laundry shut-down or would enhance the viability of the shutdown.

For example, the team reviewed how laundry was folded and prepared for delivery to individual units. We found that the sheet-folding process required two people due to our folding style, which was a fan-fold for bed-bound residents. As we have very few (if any) residents who stay in bed 100% of the time, the need for fan-fold was not justified.

Additionally, sheet-folding productivity could be increased by utilizing a sheet-folding pole, thereby reducing the number of workers needed from two to one.

Step 5: Team Recommendations

The team developed five major recommendation categories. Each category contained the following information for the steering committee: the problem, the impact, what it would take to correct the problem, the current cost in resources, the cost to correct the problem and the projected savings in resources and materials.

The team utilized a group consensus approach for each step of the recommendation formulation process. Each recommendation was then assigned to one or more group members for oral presentation to administration. One practice session was held to ensure each team member was confident and knowledgeable about the process, statistics and anticipated questions.

The five recommendations for effective laundry shut down were as follows:

1. Invest in a sheet-folding pole.

2. Invest in an additional washing machine for small loads.

3. Invest in a new linen item called "flannels" to replace the existing linen type used for incontinence.

4. Invest in larger-sized bed pads.

5. Invest in additional fitted incontinence undergarments.

As you will note, the word "invest" is used over and over again. The key to success was through cost analysis based on process evaluation and data collection in order to justify the recommended "investment" for future positive outcomes.

The steering committee agreed to all five recommendations with some stipulations. Investments would need to be prioritized and integrated with the monthly laundry budget adjustments, and timelines developed for implementation.

Investing in a new washing machine was found to be cost-prohibitive at the moment. We will be looking for a used washer over the next two to four years to augment our current laundry equipment.

Step 6: Preparing for Shut Down

The team determined how long it would take to procure the new purchases, identified a target laundry shut-down date and developed a plan for facility-wide education about it. The team believed that staff education was paramount to achieving successful outcomes. There could be no misunderstandings about the team's work, the process being redesigned, the impact on all units and the expected outcomes.

Education consisted of poster displays, flyers and one-on-one discussions. With a staff of approximately 275, education would be each team member's responsibility, with guidance and support from the facilitator and the education department.

Step 7: Shut-Down

The laundry department began "shut-down" on February 1, 1997, from 1:00 a.m. to 5:00 a.m. The first night was celebrated with cake, goodies, balloons and banners throughout the building. All shifts "celebrated" and were encouraged to make this new process work. Team members came in at night for shift change several weeks prior to "D-day" and were on hand for the actual shut-down.

The laundry staff who would shift to other work hours were kept on duty from 1:00 a.m. to 5:00 a.m. for the first week of closing. The purpose was to provide education to the night shift and reassure them that the process would work.

Step 8: Outcome Analysis

It has been six months since "D-day." The first month had a few ups and downs, such as missing linen, new linen not being absorbent enough and some staff dissatisfaction. Meetings were held with each nursing shift and laundry staff to discuss these issues. The process producing poorly absorbent linen - inadequate prewashing - was corrected, with immediately improved results. Staff satisfaction improved by our obvious willingness to resolve the problems they brought forth.

Current analysis shows linen levels constant, staff satisfaction good and machine repair costs lowered. Prior to shut-down, it was common for nursing staff to call or physically go to the laundry room looking for linen each shift. Now there are no calls, and no one comes looking for linen. Electricity cost is down by 10%, and chemical costs were down by 31% for the first six months of 1997. Additional savings could be calculated if one were to measure laundry department productivity, decreased skin problems and savings on repairs and resource shifting.

The number of wash loads has remained constant for the hours that the laundry department is operational. We have changed the type of linen we use and have effectively changed how staff use the linen. We have also adjusted the chemical delivery system to standardize the amount of chemicals being delivered during each type of wash cycle. This has resulted in a more efficient wash/dry process.

An informal staff survey shows no linen problems, no complaints about linen and no continued concerns about the laundry being closed at night. Team members spot-check linen closets for inventory, and beds and wheelchairs for proper linen use. Linen utilization shows the right item being used at the right time for the right purpose.

For now, our results are excellent. Our challenge now is to hold the gain.

Bibliography

Leebor W, Ersoz CJ. The Health Care Manager's Guide to Continuous Quality Improvement. American Hospital Publishing, Inc., 1991.

The Team Memory Jogger[TM]. Goal/QPC and Joiner Associates, Inc., 1995.

The Team Handbook, 22nd printing. Joiner Associates, Inc., September 1994, copyright 1988.

Pike B, Busse C. 101 Games for Trainers. Lakewood Publications, Inc., copyright 1995.

Pike B, Busse C. 101 More Games for Trainers. Lakewood Publications, Inc., copyright 1995.

This article is adapted from CAHQ Forum, the official publication of the California Association for Healthcare Quality, Volume 20, Number 3, 3rd Quarter, 1997. With permission.

Gail J. Rhoades, BSN, CPHQ; Allyson Andrews-Nelson, BSN, assistant director of nursing; and Antonio Incencio, director of environmental service, are on the staff of the Life Care Center of Hilo in Hilo, Hawaii.