IN THIS ISSUE: The Power of Storytelling in Change Management P. 1

Recognize Your Moment of Obligation P. 1

Discharge before Noon P. 2-3

Division Incentive Metrics FY2014 P. 4

There’s nothing new about storytelling. Long before we had books and newspapers, advertising and the Internet, our ancestors sat around the fire and told stories. More than storytellers, we’re story consumers. As doctors we all have a deep sense of what motivates us to practice medicine (the why), but we are taught to focus on how to practice medicine. When we teach our trainees, we teach them how to practice medicine too. The why should be obvious, right? Not so. It is challenging to motivate people to change behavior. You can’t just order people to “be more careful” or to “get motivated” or to “start loving your job.” The human brain doesn’t work that way. But you can lead them there with a good story. A story is a vehicle that puts facts into an emotional context. When you tell people a story that exemplifies what you believe, it inspires people to believe as well and to act in accordance with those beliefs. Storytelling is particularly helpful when trying to inspiring the organization, setting a vision, teaching important lessons, defining culture and values, and explaining who you are and what you believe. Choose stories that are appropriate for the occasion; they're relevant and have the right level of drama. Think of stories in advance so that you have an arsenal you can draw on again and again. Brainstorm past events, such as important times in your life — childhood, adolescence, young adulthood — what you learned, and who you learned it from — teachers, bosses, mentors. Jot down any stories you remember and the emotions they might elicit.

Monthly Quality Improvement Newsletter for the Division of Hospital Medicine

September 2013 � Issue 33

Greetings from DHM QI! QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE

The

Post

Welcome to the 33rd edition of The Quality Post. In this issue we go in depth to explore how we can improve our discharge times. We also look at our first months performance on our new Division Incentive Metrics.

Recognize Your Moment of Obligation People who successfully tackle big problems are often driven by a specific event or time in their lives when they felt compelled to act. These “moments of obligation” can drive you to start working on a problem, and keep at it when you might feel like giving up. They help us shape meaningful careers and lives. Here’s how to recognize your own mission-defining moment: It’s strong. The experience will invoke intense feelings. The moment itself doesn't necessarily need to be dramatic, but what it brings up in you is. It’s personal. Moments of obligation are often connected to your own experiences, or the experiences of people you care most about. It takes hold. These moments often scream for your attention, creeping into your mind when you are minding your own business — sitting on the couch, watching TV, or trying to sleep.

The Power of Storytelling in Change Management

Discharge before Noon – DHM Initiative .

 

Discharging patients before noon has benefits!

• Frees up a bed for your patient who has spent the night in the ED • Allows for transfer of your patient out of the ICU • Allow transfer patients to come during the day decreasing

handoffs between day & night attendings • Nurses have more resources during the day to help with new

admissions • Timely discharge improves patients satisfaction

Discharging patient before noon doesn’t mean all patients go home before noon!

Discharging patients before noon is possible!

• More communication with Case Managers about patients readying for discharge

• Increased awareness and discussion of discharge milestones.

While at the face of it “Discharge before noon” appear to be an initiative with the goals of increasing throughput and maximizing revenue, there are numerous arguments that earlier discharge could improve quality and patient satisfaction.

No, this is not a graph from UCSF.

But it the percentage of patients discharged by noon from a tertiary care, large, urban, university hospital at an academic medical center. How did they achieve higher rates of discharge by noon?

0:00

7:12

14:24

21:36

Dec-12 Jan-13 Mar-13 May-13 Jun-13 Aug-13

Hospital discharge time on 14L & 14M

HOSP DC TIME Linear (HOSP DC TIME)

If every team discharged just

one more patient by noon per week

we would reach 20% of patients discharged by noon

Can Tee Time help us?

 

• Launch Pad List: A running list of team patients to be discharged in the next 24 hours • CM email: An email to the entire team from the case manager about the discharge

milestones discussed in MDR • Attending reply: Attending email anytime regarding any critical status updates

The other option would be for the CM to update the sign out notes of each patient with discharge milestones.

If one of the goals is more communication, it is going to have to be sustainable & reliable for it to work. Tee time provides another point of contact.

GOAL OF TEE TIME: To identify discharges in the next 48 hours and address discharge milestones earlier in the hospitalization.

From this…

The current afternoon check in between CM and teams is not standardized and current expectations are unclear.

A new system is needed to identify potential discharges and start the work earlier. Creating a list of anticipated discharges and the tasks for each patient for the whole team to see will help address discharge milestones earlier.

… To this!

Stories from Case Review

 

The Case: 49 year old man with obesity, obstructive sleep apnea and methamphetamine use causing ILD, was transferred from outside hospital for worsening shortness of breath on high flow nasal cannula. He was determined not to be a transplant candidate, but unable to be discharged given his O2 requirements. On HD #9 just a half hour after being given his evening medications, he was found unresponsive by staff in the corner of the room pulseless, off O2, and off CPO. A code was called and he was successfully resuscitated and transferred to the ICU, but was eventually transferred to comfort care. Case Findings: - Patient had been routinely using a non-rebreather to ambulate around his room in conjunction with his high flow nasal cannula without incident. - His nasal cannula and CPO were found laying on the bed, leading providers to question whether this may have been intentional. - The lack of timely response to his CPO alarm was investigated and telemetry techs report that there are numerous “false alarms” on CPO daily per patient, so it is challenging to notify the correct nurse in a timely manner for all alarms. Recommendations: - Decreased use of CPO unless patients really need it could decrease false alarms and allow nurses to respond to alarms in a timelier manner.

The Case: 57 year old woman with a history of bilateral lung transplant complicated by rejection transferred from an outside hospital for sigmoid colon perforation. Patient developed abdominal pain on day of admission and referred to an outside ER, where a CT showed a perforation. Patient with stable VS, but with significant pain and anxiety. General surgery was notified prior to patient arrival.

On arrival patient was found have severe sepsis and was urgently transferred to the ICU. Resuscitation was limited by poor IV access and antibiotic administration of vancomycin prior to zosyn with progressive hypoxemic respiratory failure. Surgery was consulted and the patient taken to the OR later that afternoon. Patient was eventually discharged two months later to a rehab facility with a tracheostomy and J tube. Case findings: - Patient admitted to medicine given complexity, but surgery appropriately notified and consulted. - Though patient was hemodynamically stable at the outside hospital, the combination of a perforation & immunosuppression would have made the ICU more appropriate. - The timing of surgery was appropriate, the patient required stabilization of BP and respiratory status.

Recommendations: - Notify appropriate consulting specialties prior to transfer, especially if emergent surgery may be needed. - Consider increasing the level of care for septic patients being transferred from other hospitals, especially those who require source control.

Division Incentive Metric Performance

Increase  percentage  of  patients  with  telemetry  discharged  in  48  hours  by  15%   ì  

FY  2013  Compliance  6  of  12  quarters  46%  of  patients  with  

telemetry  dc’d  in  48  hours  July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 43% 44%

Improve  Blood  Utilization  by  decreasing  units  of  blood  transfused  for  a  Hbg  <7.6  by  15%   ì  

FY  2013  Baseline:      

6  of  12  quarters  52%  transfused  for  Hgb  <7.6  

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 61%

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

FY  2013  HCAHPS  Top  Box  Score:   6  of  12  months  75.6%  

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 78% 67%

Discharge  20%  of  patients  by  noon   ì  FY  2013  by  floor:  

6  of  12  months  88%  

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun 11%

Respond  to  >90%  of  nurse  clinical  documentation  improvement  queries     è   FY  2013  Baseline:    

 

9  of  12  quarters  84%  of  Nurse  Queries  

July Aug Sept Oct Nov Dec Jan Feb Mar April May June 91%