Maximizing Positive Maximizing Positive Patient Outcomes through Patient Outcomes through

the Care Improvement the Care Improvement Team:Team:

A Partnership with Patients and A Partnership with Patients and StaffStaff

Martie Carnie, AS, PFACColleen Zidik, BSN, MBA, RN

Debra Moody, BSN, RNCarolyn Hayes, PH.D, RN

In the Beginning: In the Beginning: Changing the CultureChanging the Culture

1997: Joint Venture BWH & DFCI

Informational Town Meeting Active Work GroupAffiliation with IFCC

Changing the Culture: Changing the Culture: Evolution of Glitch RoundsEvolution of Glitch Rounds DFCI Inpatient beds moved to BWH

– Each patient had a personal escort/advocate – Informal rounding of Patients with Patients

Issues uncovered with informal rounds: Clinical Environmental Personnel Communication Educational

Glitch Rounds: Glitch Rounds: The Early Days The Early Days

Glitch Committee formalized by Inpatient Leaders (MD, RN, QI) with Patient Rounders– Informal weekly meetings– Members identified– Active problem solving

Quick and easy fixes Multidisciplinary solutions Sticky situations

Glitch Rounds: Glitch Rounds: The Picker EffectThe Picker Effect

QI reports influenced and prioritized the focus of the work– Clinical Issue of Emergent

Admissions: Need to bypass emergency room visits

Neutropenic Pathway Algorithms trialed

– Educational Issues: Need to follow up with patients at home

Day after Discharge Calls

Glitch Rounds: Initiation of Glitch Rounds: Initiation of Day after Discharge Day after Discharge

CallsCalls Brainstorm of Picker questions

– What do the poor scores mean?– Need more information from the patient

perspective– New Questionnaire developed using staff

and patient input (used in addition to the Picker Survey)

Staff RN on “light duty” conducted calls Partners in Excellence Award in 2000

Glitch Rounds: Glitch Rounds: The Accolades The Accolades

Partners in Excellence Award in 1998 Patient Advocate participation in Joint

Commission Accreditation visit Patient Advocates as a resource Formalized into Care Improvement

Team of today, continuing the partnership with patients and staff

Glitch Rounds: Transition Glitch Rounds: Transition to the Care Improvement to the Care Improvement

TeamTeam Membership has tripled since original Glitch rounds– Directors (MD, RN)– Patients– Staff at all levels & all disciplines

Meetings are monthly Invited Guests to address current

concerns

Care Improvement Team: Care Improvement Team: Day after Discharge Day after Discharge

CallsCalls Resource for calls was lost in 2002/2003 Gradual reduction in calls without

resource CIT Prioritized follow up calls in 2005 Staff RNs and Care Coordination RNs

conduct follow up phone calls Staff concern the call is an “intrusion”

41.86%

13.95% 18.60%2.33%

11.63%

11.63%

Medication Questions

Prescription Question

Activity

Physical Issues

Services

Follow up

Issues Identified in Follow Issues Identified in Follow up Phone Callsup Phone Calls

Press-Ganey Discharge Press-Ganey Discharge ScoresScores

0

10

20

30

40

50

60

70

80

90

100

I nstructions care at home Explain take medicine

af ter discharge*

I nstructions re:resume

activit ies*

I nform danger signs watch

out for*

Jul-Sep 05

Oct-Dec 05

Jan-Mar 06

Formation of Discharge Formation of Discharge Education Action TeamEducation Action Team

First meeting was April ’06 Discussed previous initiatives trialed Quality data presented to the team Reinforced our focus on patient education

and improving patients’ transition from hospital to home

Discharge Education Discharge Education Action TeamAction Team

Team hypothesized Bone Marrow Transplant scores would be better than Oncology scores

Follow up analysis of Press-Ganey Scores confirm hypothesis

Discharge Education Discharge Education Action Team in ActionAction Team in Action

Summer & Fall of 2006: Created “Going Home: A Discharge Guide”

Expanded team to include MD, PA, PT, OT, RD, SW, CC and Summer College Student

Ensured reading level at 8th grade Debate about “Danger Signs” Patient Education specialists worked on

patient friendly format and design Created patient survey regarding

education needs

Discharge Teaching Pilot Discharge Teaching Pilot PlanPlan

Survey patients 24-48 hours before DC Learning needs will be shared with RN Oncology Admissions on 5AB will

receive a copy of the “Going Home: A Discharge Guide” and “A Handbook for patients, families, and friends”

Discharge checklist, supplemental patient education “library”, and pre-printed plan of care trialed

Say Cheese!Say Cheese!

Pre-Pilot Survey Results: Pre-Pilot Survey Results: Educational NeedsEducational Needs

54%

46% 46%

38%

23%

Sexual Activ ity Activ ity and Exercise Symptom Management Medication Danger Signs

Pilot Survey Results: Pilot Survey Results: Educational NeedsEducational Needs

25% 25% 25% 25%

Nutrition Activ ity and Exercise Symptom Management What to Expect

Post-Discharge:Post-Discharge: Patient Feedback Patient Feedback

5 Post Discharge Surveys were conducted

No Changes recommended to the booklet

Impact on Patient’s Wife

Evaluation of PilotEvaluation of PilotDelay in starting the trial JCAHO visit in mid-JanuaryBegan as a trial with a small

supply of “Going Home Guide” Additional tools were not utilized in

pilot

Monthly Press-Ganey Monthly Press-Ganey Results: Results:

November through FebruaryNovember through February

0

10

20

30

40

50

60

70

80

90

100

Instructions care at home Instructions re:resume activities* Inform danger signs watch out for*

JJ

Outcome: Outcome: What did the data tell us?What did the data tell us?

Focus on Process! The “Going Home Guide” alone did not impact survey results!

And next, what life was like before, during, and after the pilot --- nurse and patient perspective!

Pre-Pilot EnvironmentPre-Pilot Environment

Two Pilot Units, Each have– 12 Beds– Primary Nursing Model– Patient Population is Cancer Focused

Hematologic (i.e.: leukemia) and solid tumor

Intensive chemotherapy and research protocols

Pre-Pilot EnvironmentPre-Pilot Environment

Intense Teaching Needs– Medication– Line care– Mouth care & personal hygiene– Safety needs/precautions– Activity– Diet/nutrition– Lab values

Pre-Pilot EnvironmentPre-Pilot Environment

Varied sources of information– Experience– Hospital guidelines– Other discipline expertise– Blum Resource Center

Pre-Pilot EnvironmentPre-Pilot Environment

Follow up phone call discoveries– Reveal misinterpretation of information– Find patients received conflicting information

Began work on a discharge booklet– Work put on hold in 2004– Care Improvement Team prioritized this work

again in 2006 through Action Team work

Impact of the Impact of the “Going Home Guide”“Going Home Guide”

No longer need to gather up varied pamphlets to teach patients

Guide has necessary information to be taught in a logical sequence

Every discipline can now teach from the same “page”

“Notes” section within the guide allow “individualization” of the teaching tool

Impact of the Impact of the “Going Home Guide”“Going Home Guide”

Novice RNs and Float RNs benefit from reading the guide

Frustration when “Guide” is not available

Positive responses from patients and families

Next Steps:Next Steps:

RNs will use the before discharge survey for all patients & keep in bedside book.

All disciplines can update “survey” to document teaching & patient understanding

All disciplines will use the “Going Home Guide” to teach the patient

Develop action plan for Patient Education DVDs

Success in My EyesSuccess in My Eyes--Martie CarnieMartie Carnie

Thank you toThank you to::Care Improvement Team:

Directors: Ted Alyea, MD; Carolyn Hayes, Ph.D RN

Members: Ann Hristov, PFAC; Martie Carnie, PFAC; Judie Ham, PFAC; Joe Nies, PFAC; Cynthia Jodoin, RN; Eileen Molina, RN; Ruth Muller, RN; Kerry Mahar, RN; Escel Stanghellini, RN; Andres Sirulnik, MD; Kendra Church, PA; Elizabeth Binari, RN; Ann Collins, RM; Deb Duncombe, RM; Mrinalini Gadkari, QI; Mary Lou Hacket, LISCW; Maggie Hewit, PFR; Meri Donlan, PT; Deborah Hoffman, LICSW; Michael Hubner, LICSW; Jennifer Kales, RN; Christine Sousou,PT; Lynne Simonelli, RN; Colleen Zidik, RN

Thank you toThank you to::Discharge Education Action Team:

Members: Ann Hristov, PFAC; Martie Carnie, PFAC; Patti Smith-Allen, RN; Debra Moody, RN; Susan McDonald, RN; Eileen Kelly, RN; Dianne Griffin, RN; Susan Bolton, RN; Pamela Thomas, RN; Soheir Elebiary, RN; Joan Deary, RN; Katie Filipon, RN; Ruth Muller, RN; Ann LaCasce, MD; Andres Sirulnik, MD; Heather Hylton, PA; Sara Dorfmier, PA: Mrinalini Gadkari, QI; Meghan Cunningham, RD; Cara Dejong, RD; Nicole Varady, RD; Bruce MacDonald, LICSW; Kim Peterson, LICSW; Patricia Dwyer, LICSW; Mary Lou Hacket, LICSW; Meri Donlan, PT; Christine Sousou,PT; Carol Ann Orrico, RN; Ann Furey, RN; Danielle Sullivan, Program Assistant; Susan Decristofaro, RN; Tamara Sobers, Student; Colleen Zidik, RN

Thank you to:Thank you to:Nursing Staff on 5AB: Lela Tatarouns, Christine

Leonard, Laura Allaire, Kathleen Slack, Debra Moody, Patti Smith-Allen, Dianne Griffin, Eileen Kelly, Nancy Murphy, Katie Fiel, Ana Velez, Suzanne Badavas, Mary Chinian, Suzanne Corsetti, Paula Digiovine, Kerri Flynn, Colm Gormley, Elizabeth Halloran, Yi Jin, Kristen Kane, Susan Kenney, Allison Konefal, Karen Legere, Kathleen McCarthy, Barbara Mullins, Lisa Olivo, Maria Raleigh, Kay Sweeney, Jennifer Wright, Doreen Bannon, Gina Coniglio, Maureen Conley-Rogazzo, Christine Cox, Sheryl Fernandez, Nancy Green, Kim Irwin, Danielle Johnson, Teresa Queally-Hanley, Jean Quinn, Marianne Saleda, Tracey Slaven, Karen Valliere, Angela Whitter

Secretarial Support: Derlin Ryner, Maureen Mohansingh, Leah Pearlman;