Post on 31-Dec-2015
description
Transitions of Care20,000 Days Campaign Learning Session 3
11-12 March 2013
Clinical Lead: Martin Chadwick
Team members:
Dr Ajay Kumar, Annelize de Wet, Dr Beven Telfer, Brian Gabolinscy, Dr Carl Eagleton, Carolyn Kemp, Catherine Simpson, Chee-Khiang Sng, Clivena Ngatai, Diana Dowdle, Dot McKeen, Erin Currie, Fionna Winter, Fran Birt, Galumaninoa Tasi-Perez, Gregory Winkelmann, Helen Thomas, Ian Kaihe-Wetting, Janene Lawrence, Dr Jeff Garrett, Jo Goodfellow (GAIHN); Karla Rika-Heke, Maika Veikune, Marie Chester, Michele Carsons, Moana Houia-Poka, Penny Wilkings, Ruth Prakash, Sanjoy Nand, Sarah McMullen-Roach, Simon Kerr, Jessica Ryan, Deanna Williams (POAC)
20,000 Days Campaign Project Support: Prem Kumar (Improvement Advisor)
Monique Davies (Project Manager)
Refining Our Aim
Transitions of Care was a very large collaborative with an even larger brief of improving the inpatient
hospital journey and reducing unnecessary delays to discharge.
Our original aim:
- By 01 July 2013, we will improve the MMH inpatient journey from admission to discharge by utilizing a goal date for discharge and looking to reduce the average length of stay by 0.2 bed days within medical and surgical inpatient services. To assist in reaching this goal we will look to facilitate earlier notification of referrals to appropriate inpatient services and diagnostics, nurse led discharges and weekend discharges. We will also work on our transition of care processes with the patient’s primary healthcare provider.
By focussing our improvement work on two work streams: the patient's Goal Discharge date (GDD)
and improving the volume of Weekend Discharges we have accomplished a firm direction for testing
our improvement ideas.
The following two slides show our PDSA progress…..
To improve the admission to discharge process of
Middlemore Hospital
inpatients by 01 July 2013
Discharge planning
Weekend discharge
Change Concepts Specific Change Ideas(PDSA tests)
Measures:1. ALOS2. Readmission3. Pt Experience
Transition of CareDriver Diagram-v5Date: 4 July 2012
Primary Drivers Secondary Drivers
Discharge documentation
Discharge decision making
Ward round
MDT availability
Quality of documentation
Timeliness of documentation
Home+ community
services
community resources
Transfers
Communication
St John ordering process
Timely decision making
Standardisation
Improve transport delay
Discharge communication
POAC
STAAR
×GDD for each patient X
Care pathway
Pilot nurse led discharge
PT self mgmt
Pt involvementFamily
Availability
?
Advice family on EDD
Discharge checklist in ward X
Verbal handover
Post Disch phone callPrevention(Rapid Response)
Patient awareness on EDD
Discharge clinical decision
making
Availability of Consultant
×Rapid ward rounds
Accessibility
Measures:1. LOS2. Readmission3. # of Pt discharged
Tertiary Drivers
Treatment
Admission Process
Access to Diagnostics
Coordination
Ticket for Discharge
MDT Access
Measures:1. LOS2. Readmission3. Pt Experience
Pt Education
Discharge /Transition lounge
Effective handover
communication to family
Communication to Primary/Res. care
Bloods
X-Ray, U/S, CT
Simplify
Advance Planning
Shared care plan
Access to Diagnostics
Patient held care plan (Passport)
Self Dx
Combined EDS for all service (MDT led Dx)
Use A2D planner for Dx
Pt booked in for GP post Dx
Share team contact with pt for Dx follow up
Increase the use of POACPt to have Dx date & time
CMDHB to own and have equipment
Stoking of equipment
Correct Prediction of equipment
7 day staffing
Weekend rounding
Formal process for Pt review-Task Mgr
Std wknd plan-Dx info in one place with reasons
Goal Discharge Date
Establish GDD & Daily Review
Pt awareness on GDD
Staff awareness on GDD
Check consultant aware of GDD in mind
Doc to use care plan to review GDD-Ruth/Michele 5/12
Is the GDD documented on care plan?
GDD mentioned in notes
# of clinical directors believe in establishing GDD
GDD given to surgical pt and any plans documented
Pt awareness on GDD-Surgical
Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS
To have a standardised process to provide each patient with a GDDHow and what is the best way to establish a GDD?
To have a standardised process to share GDDBest way to communicate the GDD to patient and interested parties?
Aim: To improve the number of inpatients having GDD from 0% to 100% alsoTo increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013.
Achieving the GDD
To have the processes in place to achieve the GDDHow can we achieve the GDD as a team
Sharing GDD
Patient & Family
Drs
Staff
Other Services
Update GDD on white board
Update GDD on WiMS
DOC to use care plan for updated GDD info
Nurse to inform Pt-Ruth
Ascertain ref process in ward 6
Delay in x-fer to rehab
Referral system assessment & documentation from acute to AT&R
Early Dx if Pr referred to NASC earlier
E-referral – Erin 5/12
Timely task referral
GDD in MDT meeting
Nurse setting the GDD
GDD match with actual Dx date
Reasons of Pt waiting on Bed
CAT tool to indentify why Pt waiting
CAT tool usefulness
Post ward round delay in services for Pt > 7 days
Pt less than 48 hour
Repeat PDSA
Active PDSA
Adopt
Adapt
Abandon
What's Happening
Who, How, When?
Transition of CarePDSA TreeDate: 27/11/2012 Reviewed 27/02/2013
PDSA box
Identifying Pt need @ admission in EC(Ajay Kumar/ Fionna W)
Staff to set a GDD based on the top 10 DRGs-Michele 5/12
GDD by Doc post acute ward round – Brian 17/12
Reason of GDD not met-Ruth& Michele 12/12
Cultural Support to inform – Maika/Ian 23/12
Doc reviewing /confirming GDD-Ajay 5/12
What ref system are available in service dir.
Identifying Pt need @ admission in EC 4 pts(Ajay Kumar/ Fionna W) 13/1
Microsoft Word Document
GDD in ward 33Janene & Michele 23/1
Discharge to HHC
Process MapJanene/Michele 23/1
Known patient dx communication to HHC Owner: Prem Kumar
HHC to receive Dx list twice daily
Repeat with interventions
Goal Discharge Date
PDSA Summary Tree
Active PDSA
7
Weekend Discharge
Nurse Facilitated Dx
Aim: By 01 July 2013, we will increase by 20% the number of Middlemore Hospital medical and surgical inpatients discharged on Saturdays and Sundays.
3 Day Dx for weekend (OT)
Criteria Led Dx
Who, How, When?
Transition of CarePDSA TreeDate: 27/02/2013
Using task manager for
medical review-Brian
13/2
Increase referral to
POAC
All patients have
weekend plan
Identify the criteria for
Dx
How many didn’t meet criteria & why? Fionna 5/12Process
Mapping
All Pt have weekend plan
Measures:No of weekend DxReadmission rate
Measures:No of NFDx
Measures:No of referrals
To identify pt with no clear plan and
require a non medical input –
Fionna 5/12
Identify the Dx patient on Friday –
Fionna 5/12
Call On Call Dr to clear the delay in
Dx for non medical reasons –Fionna
13/12
Measures:Weekend plan are clear
How many weekend reviews
Active PDSA
Adopt
Adapt
Abandon
What's Happening
PDSA box
1.Clarity on why they waiting on
weekend2.Why not clear
Delay due to IV
Test Ward 2 template for weekend plan-Sarah
Rest home baselinePenny/Prem
Knowledge & understanding
Causes of less ref-Clivena 20/2
Test the template in medical ward-
Fionna 13/2
Transfer to AT&R
Pt Transfer
Identify delay in Dx (OT) -Sarah
Using task manager for
NFD referral –Fionna 13/02
Identify the reasons for delay with Radiology -Beven 20/02
Fit for Dx but delay due to rest
home 30/01
Active PDSA
9
Ward 2 identification of
pt for POACBrian/Fiona
Reasons for delay in tfr to rest home on 10 pt-Fionna 27/02
Chart review to ascertain reason for
delay for PICC
No Time Barriers to Dx to RH – David
Lange RH
Weekend DischargePDSA Summary Tree
Goal Discharge DateChange Packages Examples
Secondary Drivers Change Concepts and Ideas for PDSA Testing
Establishing a GDD for each patient in Ward 6
October 2012: Start dateFebruary 2013: Rollout to Wards 2 and 33N
Methods of establishing GDD trialednurse setting GDD on admissionGDD following medical ward roundSet at daily MDT meeting (Mon-Fri only)GDD set and recorded consistently (recorded on run chart weekly)Recorded on ward whiteboard, WiMS reports and ward round bookAccuracy of GDDReview actual discharge date with GDD (recorded on run chart weekly)Review of GDDReviewed on ward rounds and at 8.00am MDT meeting (Mon-Fri only)Establishing a GDD for each patient in Wards 2 and 33N (Start date: January 2013)Weekly data collection per ward of GDD consistency and accuracyFollowing review of data from three wards there is a higher degree of consistency noted in ward 33N’s process, i.e. there is no differentiation in results between weekdays and weekends. Process map to look at how GDD is established and reviewed in each ward with a view to standardization of process Accuracy of GDD PDSA on 3 wards, 5 patients each and recording reasons for a change in GDD ALOS per DRG Setting GDD
oPDSA on 5 patients on ward 6 having a GDD using the DRG ALOS chart.
Goal Discharge DateChange Packages Examples…cont
Secondary Drivers Change Concepts and Ideas for PDSA Testing
Sharing the GDD To facilitate ongoing communication about discharge-related issues between patients/ families, ward staff and allied health services.
Patients advised on ward rounds of likely GDD Ensure that all staff are aware and working toward the agreed GDD Audit on wards to review patient knowledge of the GDD Maori whanau support worker to ensure their patients (from IPO5 lists) on
wards 6, 2 and 33N are aware of their GDD Repeat PDSA with Pacific cultural support teams
Achieving the GDD The aim is to promote patient satisfaction and encourage timely discharges by ensuring that everyone is expecting and prepared for discharge.
Knowledge of a patient’s GDD prompts allied health and ward staff to discuss what else needs to be done to meet the goal discharge date.
6 week PDSA in ward 10 (weekend discharge group) looked at reason for delay to discharge. Data to be reviewed and PDSAs to look at resolving specific delay issues
Discharge to Home Healthcare (PREM TO ADD)
Weekend Discharge Change Package Examples
Increased referrals to POAC
Establish baseline data for current volumes of POAC referrals from Middlemore Hospital (assisting early discharge for patients)
Collecting data on why surgical staff are not using the POAC service (if beds available on the ward staff perception no need to POAC)
Increasing awareness of POAC services to nursing and medical staff
Criteria Led Discharge Decrease LOS Morning discharges
possible! Increase in weekend
discharges Improved quality of
discharge planning Increased patient and
staff satisfaction
New inter-collaborative group to be formed “SMOOTH Transitions”
A generic format to be developed and PDSA tested in a test ward
Secondary Drivers Change Concepts and Ideas for PDSA Testing
Weekend plans for Patients All patients to have a weekend planIdentify patients with no clear weekend plan, discuss with team6 week PDSA in ward 10 (weekend discharge group) looked at reason for delay to discharge.Trialing use of weekend plan template (used in ward 2) in one of our PDSA wards with a view to reducing delays
Weekend Discharge Change Package Examples…cont
Nurse Facilitated
Discharge (NFD
established in medicine:
looking to better
utilisation rates)
Considerably fewer discharges take place over the weekend compared to weekdays.
The provision of a weekend nurse facilitated discharge process assists to increase
discharge volumes on weekends when medical staffing numbers are reduced.
Increase the number of NFD discharges on weekends by:
• Criteria for discharge by NFD established and shared with staff• Increase knowledge of NFD weekend service with medical teams. PDSA testing
with one team not currently utilising the NFD service to see if increased awareness results in increased referrals to NFD
• Review patients referred to NFD for discharge on Saturday and criteria not met, record reasons why? Look at referring to medical team to review on Sunday to see if fit for discharge to increase rate of successful discharges vs NFD referrals
• NFD team to identify and accept referrals for patients appropriate for NFD over the weekend on Friday afternoons
• Use the 10 day list (i.e. patients with current LOS in hospital > 10 days) and review reasons for length of stay and facilitate access to discharge where appropriate
• Investigate via PDSA use of task manager for NFD referrals
Secondary Drivers Change Concepts and Ideas for PDSA Testing
Most Successful PDSA Cycles?
One of our most successful test of change was around the communication of
GDD to staff and other services.
Change Idea: to communicate the GDD to the multidisciplinary team by pitting the GDD on the WiMS sheet
Learning/Outcomes:updating of GDD in WiMS assisted the information about
the patient’s GDD to be readily available to all staff involved in that patient’s care at any time
Measures Summary
DecNovOctSepAugJulJ unMayAprMarFebJan
60
40
20
Month (2012)Tota
l num
ber
of
Refe
rral to
PO
AC
_X=38.42
UCL=66.22
LCL=10.61
DecNovOctSepAugJulJ unMayAprMarFebJan
30
20
10
0
Month (2012)
Movin
g R
ange
__MR=10.45
UCL=34.16
LCL=0
Total Number of POAC per month from MMH
Version: 1.0Dated: 20/02/2013
Transition of Care February 2013 Dashboard
Contacts Clinical Leader: Martin ChadwickProject Manager: Alison Howitt Improvement Advisor: Prem Kumar
MMHMMH
1
5 3
24
6
Average Length of Stay
UCL
CL
LCL
3.40
3.60
3.80
4.00
4.20
4.40
4.60
4.80
5.00
Jul 2
00
9
Oct
20
09
Jan
20
10
Ap
r 2
01
0
Jul 2
01
0
Oct
20
10
Jan
20
11
Ap
r 2
01
1
Jul 2
01
1
Oct
20
11
Jan
20
12
Ap
r 2
01
2
Jul 2
01
2
Oct
20
12
Jan
20
13
Ap
r 2
01
3
Jul 2
01
3
AL
OS
Readmission rate
CL
UCL
LCL
3%
4%
5%
6%
7%
Jul 2
009
Oct
200
9
Jan
2010
Apr
201
0
Jul 2
010
Oct
201
0
Jan
2011
Apr
201
1
Jul 2
011
Oct
201
1
Jan
2012
Apr
201
2
Jul 2
012
Oct
201
2
Jan
2013
Apr
201
3
Jul 2
013
Rea
dm
issi
on
Rat
e
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
105
90
75
60
Month/ Year
Avera
ge D
aily
Dis
charg
e
__X=89.77
UCL=105.68
LCL=73.85
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
40
30
20
Month/ Year
Sam
ple
StD
ev
_S=27.82
UCL=39.23
LCL=16.41
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
7
7
2
Tests performed with unequal sample sizes
Average Daily Discharges by Month (Med & Surg only)
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
75
60
45
30
Month/ Year
Num
ber of Disch
arg
e
__X=53.26
UCL=69.15
LCL=37.37
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
20
10
0
Month/ Year
Sam
ple
StD
ev
_S=14.46
UCL=26.24
LCL=2.68
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
2222
Tests performed with unequal sample sizes
Average Weekend Discharges (Med & Surg only)
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
110
100
90
80
Month/ Year
No o
f D
isch
arg
e __X=104.39
UCL=114.83
LCL=93.94
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
25
20
15
10
Month/ Year
Sam
ple
StD
ev
_S=15.37
UCL=22.90
LCL=7.84
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
55
2222
1
1
1
1
Tests performed with unequal sample sizes
Average Weekday Discharges (Med & Surg only)
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
80
60
40
MonthYear
No fo D
isch
arg
e __X=65.14
UCL=77.76
LCL=52.52
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
45
30
15
0
Month/ Year
Sam
ple
Range
_R=17.32
UCL=39.51
LCL=0
Jul07 Jun09 May10
5
5
22
1
3
1
Tests performed with unequal sample sizes
Average Discharges on Saturday (Med & Surg only)
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
50
40
30
20
Month/ Year
Sam
ple
Mean __
X=41.38
UCL=52.97
LCL=29.79
Jul07 EHB Ph1-Wrd 33,34 EHB Ph 2-Gastro, 35N
Feb1
3Ja
n13
Dec
12N
ov12
Sep1
2
Jul1
2
May
12
Mar
12
Jan1
2
Nov
11
Sep1
1
Jul1
1
May
11
Mar
11
Jan1
1
Nov
10
Sep1
0
Jul1
0
May
10
Mar
10
Jan1
0
Nov
09
Sep0
9
Jul0
9
May
09
Mar
09
Jan0
9
Nov
08
Sep0
8
Jul0
8
May
08
Mar
08
Jan0
8
Nov
07
Sep0
7
Jul0
7
40
30
20
10
0
Month/ Year
Sam
ple
Range
_R=15.91
UCL=36.30
LCL=0
Jul07 Jun09 May10
2
2
5
5
2
Tests performed with unequal sample sizes
Average Discharges on Sunday (Med & Surg only)
Highlights
Direction and Purpose
The group now have clarity of direction by the focus on two work stream areas: Goal Discharge Date
and Weekend Discharge
PDSA tests are completed, recorded and discussed at weekly meetings
The IHI PDSA Methodology is now well embedded and learning is gained from each PDSA cycle, in
some instances we learn more from our ‘failures’ than our successes
Working with the David Lange Rest home on our current PDSA “No Time Barriers To Discharge to a
Rest Home” has highlighted the willingness and generosity of primary care and community
organizations to be part of our improvement journey
Strengthening of relationships between services and professions has been a highlight of working
within this group
Achievements to date
- The group have established and bedded in the process for setting a goal discharge date in ward 6 and have worked to look at rolling out to wards 33N and 2. Data on the accuracy and consistency of recording of the GDD is collected and presented weekly
- The effect of a ‘published’ GDD for patients on these wards has a marked beneficial impact on other staff in the planning and provision of allied support services
- Measurements established to look at the volume of weekend discharges, referrals for discharge to the Nurse Facilitated Discharge team on weekends and POAC assisted discharges