general pediatric discharge time project ihqi seed …...m general pediatric discharge time project...
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U N
C H
E A L T H
C A
R E S Y S T E M
General Pediatric Discharge Time Project
IHQI Seed Grant Symposium
May 5, 2015
Kathleen Bradford, MD
Heidi Troxler, MSN, RN
Sheryl Galin, BSN RN
Jennifer McElroy, MSN, RN
Kevin Kelly, MD
Melanie Dawes MBA, MHA, RN
Ian Buchanan, MD, MBA
Problem Statement:
Patient discharges on the General Pediatric
Services occur late in the day.
In calendar year 2012, < 2% of Pediatric Medical A
(PMA) discharges occurred before 1100, and
approximately 60% occurred after 1500.
PMA Patient Diagnoses and Conditions
• Pediatric Medicine A- General Pediatrics
• Pediatric Metabolic Disease
• Pediatric Rheumatology
• Pediatric Infectious Disease
• Pediatric Neurosurgery 8/2013
• Pediatric Nephrology- 9/2014
Problem Statement:
Global Aim Statement:
To increase the number of hospital discharges
by 1 PM on the General Pediatric Medical
Service (PMA) to 50%
Smart Aim Statement:
To improve the mean discharge time
of PMA patients
Hospital Discharge Process is Complicated!
Physical Process Map
Attending
Computer
HUC
Ancillary staff
CCMRN
Residents
WTC
Patient & Family
• Acute/ Chronic illness improved /stable
• Medication Reconciliation/Plan
• Home Health Plan
• Rounds-Attending/ Team see patient
• IV or other devices removed
• Prescriptions e -scripted to right home
pharmacy
• Prescriptions sent to hospital pharmacy
• Consultant/s sign off
• GT/PICC/ CVL Teaching
• Home supplies delivery confirmed
• PCP/consultant/ f/u scheduled
• Disposition – Custody issues
• Discharge Order Written
• Ride arranged/ available
• Bags packed
• Meals/ showers
• Car Seat secured
• Discharge Cart available
• Car obtained from parking lot
Medically Ready
Family Ready
Aug20
13
Jul2013
Jun2
013
May201
3
Apr2013
Mar20
13
F eb20
13
Jan2
013
Dec201
2
Nov2012
Oct2012
Sep20
12
Aug2012
Jul201
2
Jun2
012
May201
2
Apr2012
Mar20
12
Feb2012
Jan2
012
5:00 PM
4:00 PM
3:00 PM
2:00 PM
Month
Mea
n d
isch
arg
e ti
me
by
mo
nth
__X=3:36 PM
UCL=4:55 PM
LCL=2:17 PM
What time are PMA patients discharged?
D M A I CPMA Discharges
2012 Baseline
Mean=3:36 PM
3 standard errors
12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am
200
150
100
50
0
Hour of day
Fre
qu
en
cy
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/15/2015 4:50:24 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
What time were PMA patients discharged before improvements began?
1/1/2012-9/28/2013
n=1381
Mean 15:36 PM
17% before 1PM
N=1381
D M A I C
SMART AIM KEY DRIVERS INTERVENTIONS
To increase the
percentage of PMA
patients who are
discharged before
1PM once they are
identified as medically
ready for discharge
from NCCH.
Continue to identify
discharge barriers
and establish plans to
mitigate these
barriers
Revision 3.2015 KKBHBT)
Improve the
discharge process
and improve overall
patient flow through
NCCH
GLOBAL AIM
• * Identification and mitigation of process failures
Recommended Future Interventions
• Discharge Medication Improvement
• Development of standard EMR Discharge Criteria for
high impact Pediatric diseases “discharge stamp”
Empower the entire
medical team and
families in the
discharge process.
• Develop Spread plan
• Feedback discharge run charts to medical team
Create a system and
culture in which
patients ready for
discharge are
prioritized.
•Kaizen event to decrease time between discharge order
and physical discharge from NCCH
•Charge nurse to script “Steps to Home” with families after
AM huddle
• Clearly define roles in discharge process, hold all team
members accountable. Enable night team.
• Implement 6CH 8:30 AM Multi-disciplinary Discharge
Huddle
• Determine patients medically ready for discharge before
AM rounds.
• Discharge patients medically ready for discharge during
AM huddle or on teaching rounds
Discharge Time Improvement Project (DIP)
Apr15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12
8:00 pm
6:00 pm
4:00 pm
2:00 pm
12:00 pm
Tim
e o
f d
ay
__X=2:39 pm
UCL=4:51 pm
LCL=12:28 pm
Improvements began
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 5/1/2015 8:23:49 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Weekly Mean PMA Discharge Time
Mar15
Feb15
Jan1
5
Dec14
Nov14
Oct14
Sep14
Aug14
Jul1
4
Jun14
May14
Apr14
Mar14
Feb1
4
Jan14
Dec13
Nov13
Oct13
Sep13
Aug1
3Ju
l13
Jun1
3
May13
Apr1
3
Mar13
Feb13
Jan1
3
Dec12
Nov12
Oct12
Sep1
2
Aug12
Jul1
2
Jun1
2
May12
Apr1
2
Mar12
Feb1
2
Jan1
2
5:00 PM
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
Tim
e o
f d
ay
3:09 PM*
began DC order tracked
Mean PMA DC time
Mean PMA DC order timeMean PMA Discharge Time by Week
**Mean PMA DC time last week
***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/16/2015 11:35:01 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]
*Mean PMA DC time since 1/1/2012
Improvements Epic Go-Live &
2:26 PM**
1:03 PM***
Maintaining Gains & Continuing Improvement
• Kaizen (LEAN) event February 23-27, 2015
• Decrease time between D/c order and physical discharge
• Current State- 1hr 44 minutes
• Culture change in process- discharge is
priority.
• Family delays- restaurant delivery,
showers, packing.
• Staff Delays- Unit clerk notification to
nurse of discharge order, discharge
cart.
• Ongoing areas for improvement-
Discharge medication
• Dietary Staff cannot see discharge
order
• Scripting for nursing/ medical team for
anticipated discharges
• “Steps to home” education sheet for
families
• Staff education
• CCM pilot of arranging transportation
in some cases
• Use EPIC anticipate discharge order
for next day’s anticipated discharges
• Record attendance at morning
discharge huddles
• Investigate process of take away
meals
Insight Action
Time from discharge order to actual discharge—97
minutes during week of Kaizen
Family Education Sheet
Apr1
5
Mar15
Feb1
5
Jan1
5
Dec14
Nov14
Oct14
Sep1
4
Aug1
4Ju
l14
Jun14
May14
Apr14
Mar14
Feb14
Jan1
4
Dec13
Nov13
Oct13
Sep13
Aug1
3Ju
l13
Jun13
May13
Apr13
Mar13
Feb13
Jan1
3
Dec12
Nov12
Oct12
Sep12
Aug1
2Ju
l12
Jun12
May12
Apr1
2
Mar12
Feb12
Jan1
2
5:00 PM
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
Tim
e o
f d
ay
began DC order tracked Discharge Kaizen
3:07 PM*
Mean PMA DC time
Mean PMA DC order time
Mean PMA Discharge Time by Week
**Mean PMA DC time last week
***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 4/20/2015 12:19:38 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Improvements
*Mean PMA DC time since 1/1/2012
Epic Go-Live &
2:26 PM**
12:42 PM***
As of 04/18/2015
12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am
200
150
100
50
0
Hour of day
Fre
qu
en
cy
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 12:16:02 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
9/29/13-4/18/15When are PMA patients discharged now?
n=1439
Mean discharge time=2:39 pm
32.38% discharged before 1 pm
Mean 14:39 PM
9/29/2013-5/2/20151/1/2012-9/28/2013
After 1 pmBefore 1 pmAfter 1 pmBefore 1 pm
1200
1000
800
600
400
200
0
Nu
mb
er
of
dis
ch
arg
es
998
477
1150
231
Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 5/5/2015 8:45:38 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]
PMA patients discharged before and after 1 pm
17%
83%
32%
68%
Results
Are results significant?
• Differences between discharge times before and after the
Green Belt project continue to be statistically significant.
• Differences from Kaizen are not currently statistically
significant.
Percent of
discharges
before 1 pm
Mean
discharge
order time
Mean time
from DC order
to actual DC
Total
discharges
Average
discharge
time
Before
(1/1/12-
9/28/13)
17 2:06 pm in
2012
1 hr 44 min in
2012
1381 3:36 pm
After GB
(9/29/13-
02/21/15)
32 1:05 pm 1 hr 46 min 1281 2:41 pm
Kaizen
(02/22/15-
04/25/15)
34 12:42 pm 1 hr 42 min 174 2:24 pm
Mar15
Dec14
Sep14
Jun14
Apr14
Jan14
Oct13
Jul1
3
Apr13
Jan13
Oct12
Jul1
2
Apr12
Jan1
2
6
5
4
3
2
Me
an
len
gth
of
sta
y (
da
ys
)
_X=3.745
UCL=5.601
LCL=1.889
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 2:27:51 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Length of stay for PMA patients
January 2012-March 2015
Challenges/ What We Learned
1. Reaffirm that Discharge is complex/complicated
process
• Break down process with multiple PDA cycles
2. Discharge Huddle has been very effective
3. Early communication with Charge Nurse/ CCM
4. Cultural Change/Late Adopter
• “Work of day” has shifted to the AM
• Ongoing feedback to the teams
5. Patient Specific Discharge Goals or “Green Sheets”
Project “ hot potatoes”
Challenges/ What We Learned
6. Spread - PMB team
7. Epic Roll Out
8. Weekends
• Expectations are different on the weekends
9. Resources
• Discharge take away meals
•Discharge carts
6. Future PDSA/PDCA cycle focus
• Discharge patients when they are medically ready
• EMR patient specific goals- Discharge Stamp
• Discharge Medication Process
• Night Attendings
PMA Discharge Time Project Team
IHQI Center; Laura Brown, MPH; Tina Willis, MD; Mike Pignone, MD
Kevin Kelly, MD, Pediatrician In Chief
Acknowledgements
U N
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Appendix
Apr1
5
Mar15
Feb1
5
Jan1
5
Dec14
Nov14
Oct14
Sep1
4
Aug1
4Ju
l14
Jun14
May14
Apr14
Mar14
Feb14
Jan1
4
Dec13
Nov13
Oct13
Sep13
Aug1
3Ju
l13
Jun13
May13
Apr13
Mar13
Feb13
Jan1
3
Dec12
Nov12
Oct12
Sep12
Aug1
2Ju
l12
Jun12
May12
Apr1
2
Mar12
Feb12
Jan1
2
5:00 PM
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
Tim
e o
f d
ay
began DC order tracked Discharge Kaizen
3:07 PM*
Mean PMA DC time
Mean PMA DC order time
Mean PMA Discharge Time by Week
**Mean PMA DC time last week
***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 4/20/2015 12:19:38 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Improvements
*Mean PMA DC time since 1/1/2012
Epic Go-Live &
2:26 PM**
12:42 PM***
As of 04/18/2015
Mar15
Dec14
Sep14
Jun14
Apr14
Jan14
Oct13
Jul1
3
Apr13
Jan13
Oct12
Jul1
2
Apr12
Jan1
2
6
5
4
3
2
Me
an
len
gth
of
sta
y (
da
ys
)
_X=3.745
UCL=5.601
LCL=1.889
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 2:27:51 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Length of stay for PMA patients
January 2012-March 2015
Mar15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12Jul12Apr12Jan12
5:00 pm
4:00 pm
3:00 pm
2:00 pm
1:00 pm
5.0
4.5
4.0
3.5
3.0
2.5
Mo
nth
ly m
ea
n D
C t
ime
(ti
me
of
da
y)
Le
ng
th o
f s
tay
(d
ay
s)
Monthly mean DC time
Monthly mean LOS
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 1:02:21 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
PMA patients, January 2012-March 2015Mean Discharge Time and Length of Stay by Month
PMA Discharge Times: July 2014-present
Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14
5:00 pm
4:00 pm
3:00 pm
2:00 pm
1:00 pm
12:00 pm
Tim
e o
f d
ay
__X=2:16 pm
UCL=4:05 pm
LCL=12:26 pm
Before Kaizen After Kaizen
1
Project: PMA&PMB.MPJ; Worksheet: PMA062914-032115; 3/23/2015 3:25:57 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Mean PMA Discharge Time by Week
n=697
Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14Jun14
3:00
2:00
1:00
Tim
e fr
om
ord
er t
o d
isch
arg
e
__X=1:48
UCL=2:36
LCL=1:00
Kaizen
2
1
Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 6:54:59 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Weekly mean time between discharge order and actual discharge
PMA patients, 06/29/14-03/21/15
Time from discharge order to actual discharge
n=697
PMA Discharge Times: January 2012-present
Mar15
Feb15
Jan15
Dec14
Nov14
Oct14
Sep14
Aug1
4Ju
l14
Jun1
4
May14
Apr1
4
Mar14
Feb14
Jan14
Dec13
Nov13
Oct13
Sep13
Aug13
Jul1
3
Jun13
May13
Apr13
Mar13
Feb1
3
Jan1
3
Dec12
Nov12
Oct12
Sep1
2
Aug1
2Ju
l12
Jun12
May12
Apr1
2
Mar12
Feb12
Jan12
8:00 pm
6:00 pm
4:00 pm
2:00 pm
12:00 pm
Tim
e of
day
__X=2:16 pm
UCL=4:05 pm
LCL=12:26 pm
Green Belt Kaizen
1
2
2
2
22
2
2
22
1
2
2
Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 5:30:08 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Mean PMA Discharge Time by Week
n=2739
Discharge order vs. actual discharge
Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
Tim
e o
f d
ay
Mean PMA DC time
Mean PMA DC order time
Mean PMA Discharge Time by Week
Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 7:23:50 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
n=697
Background
• Results of Green Belt project on PMA discharges presented to this
committee in October 2014
• Key interventions from that project:
• Nursing and CCM at 1500 rounds
• Day team completes tasks for next day’s discharges
• Implement 0830 discharge huddle
• Patients discharged before or during rounds if clinically ready
• Night team rounds on next day’s anticipated discharges &
completes any discharge tasks
• Mean discharge time went from 3:36 pm to 2:40 pm, p<0.01
2.14
2.64
3.14
3.64
4.14
4.64
5.14
5.64P
MA
LO
S
PMALOS Jan12.April14
Balancing Measure PMA LOS
PMA LOS
Average
Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14Jun14May14Apr14Mar14
5:00 PM
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
Tim
e o
f d
ay
2:45 PM**
3:10 PM*
Mean PMA DC time
Mean PMA DC order time
Mean PMB DC time
Mean PMB DC order time
Mean PMA & PMB Discharge Times by Week
*Mean PMB DC time since 3/2/2014
**Mean PMA DC time since 3/2/2014Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 10:01:40 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]
As of 03/21/15
Mar15
Dec14
Oct1
4Ju
l14
Apr1
4
Jan14
Oct1
3Ju
l13
Apr1
3
Jan1
3
Oct1
2Ju
l12
Apr12
Jan1
2
4:00 pm
3:00 pm
2:00 pm
Tim
e o
f d
ay __
X=3:08 pm
UCL=4:08 pm
LCL=2:07 pm
1
1
2
2
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 3:34:04 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Tests performed with unequal sample sizes
Mean PMA Discharge Time by Month
Apr15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12Jul12Apr12Jan12
8:00 pm
6:00 pm
4:00 pm
2:00 pm
12:00 pm
Tim
e o
f d
ay
__X=2:17 pm
UCL=3:58 pm
LCL=12:35 pm
Improvements began Discharge Kaizen
1
2
2
2
222
2
22
1
2
2
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 12:09:30 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
Mean PMA Discharge Time by WeekAs of 04/18/2015
12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am
200
150
100
50
0
Hour of day
Fre
qu
en
cy
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 12:16:02 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
9/29/13-4/18/15When are PMA patients discharged now?
n=1439
Mean discharge time=2:39 pm
32.38% discharged before 1 pm
12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am
200
150
100
50
0
Hour of day
Fre
qu
en
cy
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/15/2015 4:50:24 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
What time were PMA patients discharged before improvements began?
1/1/2012-9/28/2013
n=1381
16.73% discharged before 1 pm
Mean discharge time=3:36 pm
12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am
200
150
100
50
0
Hour of day
Fre
qu
en
cy
Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/20/2015 12:16:02 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]
9/29/13-4/18/15When are PMA patients discharged now?
n=1439
Mean discharge time=2:39 pm
32.38% discharged before 1 pm