Transitions of Care 20,000 Days Campaign Learning Session 3 11-12 March 2013

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)

http://emcare.web12.hubspot.com/Portals/158207/images/Patient%20Discharge.jpg

http://spotyo.orcon.net.nz/Auckland/Picture%20247.jpg

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


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


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


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


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


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


2222


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


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


55

2222

1

1

1

1


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


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


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


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


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

Transitions of Care 20,000 Days Campaign Learning Session 3 11-12 March 2013

Documents

Transcript of Transitions of Care 20,000 Days Campaign Learning Session 3 11-12 March 2013