thequalitypost

3 Simplifying Tips to Increase Productivity Pick up the phone: An email chain can be a useful reference, but it frequently takes more time to write an email than to have a conversation. Conversations can get your questions answered immediately and prevent future back-and-forth messages. Encourage streamlining: What meetings can we eliminate? What reports can we stop doing? What steps in a process can be removed? Let your team know that their suggestions won’t be taken as complaints but as creative ideas for improving productivity. Stop reviewing low-impact work: It’s wise to thoroughly review documents, but not all work products are mission-critical. Tell your team that it’s their responsibility to ensure their own quality control — and that you trust them to do a great job.

Greetings from Michelle and Sasha QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE Welcome to the 35th edition of The Quality Post. In this issue, we feature the Six Thinking Hats method, give an update on the latest Transition Kaizens, and bring you the first few months of data on our new Division Incentive Metrics. Dr. Edward De Bono’s Six Thinking Hats Six Thinking Hats is a simple, effective parallel thinking process that can be used as an alternative to traditional brainstorming. Your team can learn how to separate thinking into six clear functions and roles. Each mode of thinking is identified with a colored symbolic hat. By mentally wearing and switching "hats," you can easily focus or redirect thoughts, the conversation, or the meeting.

White Hat: Calls for information known or needed Yellow Hat: Why it May Work; Logical Positive Green Hat: Focuses on creativity, possibilities, alternatives, and new ideas Red Hat: Signifies feelings and intuition Black Hat: Why it May Not Work; Logical negative Blue Hat: Used to manage the thinking process

This tool can make meetings more productive, reduce conflict among team members, and stimulate innovation by generating more and better ideas quickly. Want to try using this at your next meeting? Sasha can help facilitate!

Learn more at: http://www.debonogroup.com/six_thinking_hats.php

in this issue

Monthly Quality Improvement Newsletter for the Division of Hospital Medicine

November 2013 � Issue 35

DeBono’s Six Thinking Hats

3 Simplifying Tips to Increase Productivity

“The Inpatient Stay” Kaizen

“Tests, Treatments, & Consults” Kaizen

Division Incentive Metrics

Highlights of Lean Kaizen #4 – The Inpatient Stay

 

MDR & Tee time

The team worked to standardize the content provided at MDR. After the one liner from the MDs, the case managers will prompt discussion around:

• Expected length of stay • Anticipated location of discharge • Anticipated discharge/clinical needs

Another group is taking on Tee time. They are working with Molly Shane and Heather Davidson to figure out the best time, format and resulting actions for tee time.

Providing Patient’s Medication Lists Problem: Patients do not understand their medications, and there is too much teaching left to the day of discharge. Goals: Teach on medications throughout the patient’s stay, and engage the patient in medication teaching. Intervention: Patient receives their daily med list during morning medication pass as a visual aid.

Result: Nurses and patients appreciated having the medication list. It also generated discussion and highlighted some medication issues.

Patient Passport

Problem: Patients are given a great deal of information, but it is not always what they want/need, and not always usable. Goals:

(1) Consolidated source of information that is organized and readily accessible to the patient/family and staff

(2) A tool that highlights and tracks progress towards discharge milestones

(3) A framework that provides for successful transitions (inpatient and outpatient) to promote understanding

(4) A complement to other patient communication (like face cards)

Intervention: Created information packet that serves to aggregate all of the information a patient may need while in the hospital and following discharge.

The FOURTH Lean Transitions Kaizen focused on the time period 24 hours after admission to the day before discharge. It was a big undertaking and the team came up with some important interventions and improvements! Thanks to Andy Auerbach, Hemali Patel and Yile Ding for being part of the team!

Additional consults/imaging Rehab services DME Home O2 needs Home IV antibiotics Home Health Nursing

Patient Passport Thank You for Trusting

Us With Your Care

Highlights of Lean Kaizen #5 – Tests Treatments & Consults

 

Using Computer Orders for Consults & Inputting Consults by Night Team

The team recognized that consult orders for holdovers are often delayed by the business of the am sign out and rounds. The team piloted having the night team order and call consults before they left in the am.

The team created “quick consults” – Those for which all

the information could be inputted with an order & page, eliminating the need for a call.

The GI consult team was excited to pilot “order + text page only” consults!

Using Care Web and Sticky Notes for Radiology & IR procedure communication

The team members realized that coordination of tests and procedures takes multiple phone calls between the primary team, the nurse and the procedural area.

Care Web is a great solution for conversations between bedside RNs and test/procedural areas

about patient preparation and readiness.

We are hoping that we can soon spread CareWeb to procedural areas and use this as a tool to streamline communication.

As we are about a year away from a centralized radiology and IR schedu ling system, the team explored the idea of using Sticky Notes

The FIFTH Lean Transitions Kaizen focused on the Tests, Treatments and Consults. The week brought together a uniquely multidisciplinary team to break down silos of communication around test/treatment ordering. Thanks to Andy Lai and Sumant Ranji for being part of the team!

For consulting GI for GI BLEEDS ONLY: (1) Order "Inpatient Consult to Gastroenterology" as soon as you anticipate this need (after 8pm, night animals SHOULD enter this before a.m. signout) (2) In "Reason for Consult", type "GI bleed (see below)" (3) In the comments section, use the .GIBCONSULT smartphrase and fill in the above as prompted (4) For non-urgent consults (ie: you would typically not consult GI until tmrw a.m.), please PAGERBOX the GI fellow at approx 7am an FYI page about your APEX consult (ex: "Fr: Med H R1 John Smith, FYI new APEX consult ordered for pt Jane Johnson MRN#. Page me PRN w/ any q's. [pgr #]" (5) For urgent/emergent consults overnight, you can ignore all of the above and just consult GI as you typically would Pilot APEX GIB smartphrase (.GIBCONSULT) for new consult order

Sticky Notes work well for one-way, FYI information, such as when a patient is

likely to get her MRI.

Mr. Kusher should be going to MRI between 1 PM and 3 PM

- Sandy, MRI tech

 

Duration of Procedures

Is Your Patient Ready to go to… Radiology and IR are frequently frustrated by patients who come down for their procedure, but who have contraindications.

.

INTERVENTIONAL  RADIOLOGY  (IR)

INR  <  1.5 Y    /    N

Platelets  >  50  (if  the  count  is  low,  plan  to  type  and  screen  and  transfuse  before  IR) Y    /    NNPO  6  Hours  (if  sedation  needed) Y    /    NPrecautions/Isolation? Y    /    NAnesthesia  Required? Y    /    NCan  the  patient  lie  flat? Y    /    NChronic  pain? Y    /    NAltered  mental  status  (agitated)? Y    /    NHigh  O2  Required? Y    /    NContrast  Allergy? Y    /    NOrder  for  off  floor/tele/CPO? Y    /    NAnticoagulation  (Lovenox,  Plavix,  Asprin,  Coumadin)? Y    /    NHave  you  explained  the  purpose  and  experience  of  the  procedure  to  the  patient? Y    /    N

IS  YOUR  PATIENT  READY  TO  GO  TO  IR?

AREA PROCEDURE/TEST DURATIONX-­‐RAY Portable 5  MinutesX-­‐RAY PA/Lateral 5  Minutes

CT Chest 20  MinutesCT Abdomen/Pelvis 20  MinutesCT Angio 20  MinutesCT Head 20  MinutesCT Guided  Biopsy 45-­‐60  Minutes

MRI Brain 1  HourMRI Spine >=  1  HourMRI Extremities 1  HourMRI MRCP 1  HourMRI MRA 30-­‐60  Minutes

PICC Placement 1  Hour

IR Tunneld  HD/Port 1  HourIR Feeding  Tube 20-­‐120  MinutesIR Embolization 2-­‐4  Hours

GI EGD 1.5  HoursGI Colonoscopy 1.5  HoursGI ERCP 1.5  HoursGI Barium  Swallow 30  Minutes

Bronchoscopy 1-­‐1.5  HoursULTRASOUND Abdomen 30  MinutesULTRASOUND Renal 30  MinutesULTRASOUND Extremities  (DVT  rule  out) 30-­‐60  Minutes

CARDIOLOGY TEE 2  HoursCARDIOLOGY TTE 30-­‐40  MinutesCARDIOLOGY Echocardiogram 30-­‐60  Minutes

PULMONARY PFTs 30  minutes

TRANSFUSION PRBC  Transfusion 2-­‐3  Hours/UnitTRANSFUSION Platelet  Transfusion 15-­‐30  Minutes/UnitTRANSFUSION FFP  Transfusion 30-­‐45  Minutes/UnitTRANSFUSION Type  &  Cross 3-­‐4  Hours

THINGS  TO  CONSIDER:

The  patient  is  NOT  claustrophobic Y    /    NCan  the  patient  lie  still  and  flat  in  a  confined  space  for  1  hour  per  body  part  being  imaged  without  sedation/anesthesia?  (If  No,  notify  MD  and  MRI  Technician) Y    /    NHave  you  explained  the  purpose  and  experience  of  the  study  to  the  patient? Y    /    NFYI:  Only  NPO  required  for  enterography  X  4  hours  prior  to  exam Y    /    NOrder  for  off  floor/tele/CPO? Y    /    NMRI  Screening  Form  Complete Y    /    N

Contrast  patients:  current  GFR  level  (should  be  at  least  45) Y    /    NPE  Protocol  or  any  CT  w/contrast  -­‐  18-­‐20  Gauge  IV  needed  (or  Power  PICC) Y    /    NPower  Port-­‐A-­‐Cath  Needle  OK Y    /    NOrder  for  off  floor/tele/CPO? Y    /    NCT  Contrast  Assessment  Form  Complete Y    /    N

MRI  

CT  

IS  YOUR  PATIENT  READY  TO  GO  TO  MRI/CT?  

The team created checklists to ensure

patients meet criteria for their procedure.

The goal is for these checklists to be

incorporated in orders for the procedures.

A frequent complaint from patients is that they don’t know how long procedures

take or when they will be. To address the duration of procedures, this handy tip

card was created.

Nurses can use this handy reference tool to let patients know how long their

procedures will take.

Division Incentive Metric Performance

Decrease  the  percentage  of  patients  on  telemetry  until  discharge  (with  LOS  >  48hrs)  from  44%  to  37%   è   FY  2013  Baseline  

6  of  12  months  44%  

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 55% 57% 52% 49% 49% 41% 58% 50% 45% 32%

Improve  Blood  Utilization  by  decreasing  units  of  blood  transfused  for  a  Hbg  >  8.0  by  from  30%  to  25%   ¤  

FY  2013  Baseline:      

6  of  12  months  30%  

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 16% 34% 38% 23% 26% 28% 19% 18% 17% 12%

Achieve  HCAHPS  Communication  with  Doctors  Top  Box  score  above  80%   ì  

FY  2013  HCAHPS  Top  Box  Score:   6  of  12  months  

75.6%  Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

73% 74% 78% 78% 79% 81% 80% 78% 75%

Achieve  20%  of  Hospital  Medicine  Discharges  by  noon   ì  FY  2013  Baseline:  

6  of  12  months  8%  

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 9.4% 10.6% 11.4% 10.8% 10.6% 8.4% 12.1% 10.1% 12.7% 15.1%

Answer  greater  than  90%  CDI  Nurse  Queries   ¤   FY  2013  Baseline:       9  of  12  months  

86%  of  Nurse  Queries  

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 89% 85% 92% 95% 97% 92% 93% 94% 96% 91%

120

6.0% 8.0%

10.0% 12.0% 14.0% 16.0%

Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct

2012 2013

Percent discharge by noon

June

July

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

May

June

July

Aug

Sep

April 2012 2013

Each  bar  represents  the  total  #  of  transfusions  per  month                  threshold  above  8  g/dL     threshold  between  7  and  8  g/dL      threshold  less  than  7  g/dL     0

0