tracey hinke (discharge planner) shellharbour hospital ... · (adra) (n=70 pre & post) pre...
TRANSCRIPT
“When I first went into hospital no one talked to me about how long I would be in for……[Was that important?]….yeah, they should
have.” Hessi (Patient)
“I did ask to see the social worker …Well I asked 3 times and it didn’t happen. In fact the young women Dr
suggested it but it didn’t occur.” Bill Smith (Patient)
Planning & Implementing Solutions
Brainstorming solutions with staff (Dr’s= 20 Nurses = 22 Allied = 8)
Tracey Hinke : Ph: 0409569343 [email protected]
Kerrie O’Leary: Ph: 0416280830
Kerry Shanahan: Director of Nursing (Sponsor) Dr Andrew Jones: Respiratory Physician Dr Niladri Ghosh: Infectious Disease Specialist Shelly Lupton: NUM Medical Respiratory Ward Kristi Kilborn: CNE Medical Respiratory Ward
Results
89% Patients had a POSITIVE experience with care coordination
Sustaining Change
Conclusion
Case for Change
Goal
Method
Diagnostics
Acknowledgements
Tracey Hinke (Discharge Planner) Shellharbour Hospital, Illawarra Shoalhaven Local Health District Kerrie O’Leary (Acting Clinical Redesign Coordinator), Illawarra Shoalhaven Local Health District
Objectives
0%
20%
40%
60%
80%
100%
0
5
10
15
20
25
30
Nodevelopment
process
Poor staffknowledge
use
Lack info pt /carers
No agreedlocation
document
Coun
t
EDD Root Causes
Count Cumul 80%
3 patient’s for D/C – no staff informed
>7 min trying to locate D/C planner
Changes to pt care plans not communicated to staff
1hr 40min chase report – Dr’s already have report
No referrals entered into eMR
Patient Stories
Medical Record Audit
Surveys Patients - 43.2% were discharged unexpectedly
Carers - 46.9% did not know there loved ones EDD prior to the day of discharge
Staff – 8% new all patients EDD
• Business rules for new processes and forms developed
• Nursing, medical and allied health clinical competencies and education resources
• Developing ward champions • New position “Patient Journey Facilitator” to
continue spread across all wards • Project governance committee to continue
This project transformed care delivery on this ward, improving safety, patient, carer and staff
satisfaction. The model of care and resources are transferrable to any clinical environment.
Contacts
• Improve patient/carer experiences with care coordination from 20% to 50% by April 2015.
• Improve documentation of EDD’s in the medical record from 36% to 70% by April 2015.
• Increasing staff awareness of patient’s EDD from 8% to 50% by April 2015.
• Increasing the percentage of carers who are informed of an estimated date of d/c prior to the day of D/C from 57% to 70% April, 2015
• Increase number of MDT meetings at the patients bedside from 0% to 50% by April 2015.
• Improve completion of the Transfer of Care Risk Assessment (TCRA) within 24hrs of admission from 60% to 80% by April 2015.
• Improve referrals from 50% to 70% for patients with a positive TCRA by April 2015.
• Reduce the frequency of delays in referral processes (documentation in medical record to eMR entry) from 64% to 44% by April 2015.
• Reduce the median time of referral processes (medical record to eMR) from 6 – 3hrs by April 2015.
To enhance patient, carer and staff experiences by improving care coordination and
interdisciplinary communication within the Medical/Respiratory Ward in alignment with the
NSW MoH Whole of Hospital Program and Shellharbour Hospitals Service and Quality
/Safety Plan 2013-2023.
Referral Processes were inefficient - median time
delay of 6hrs from request in medical record to entry
in eMR
Problem Solving / Brainstorming
Solution Triangulation
Designed and Implemented New Model of Care
Frequency of delays reduced by 24%
The Medical Respiratory Ward at Shellharbour Hospital was not compliant with NSW Ministry of
Health’s Policy “Care Coordination: Planning from admission to transfer of care in NSW Public
Hospitals”. In addition: • only 20% of patients reported a positive
experience with care coordination. • 68% of staff felt communication needed
improvement • 0% multidisciplinary team (MDT) meetings
documented • 64% of MDT referrals were delayed • 16% of these referral delays resulted in the
patient not being seen by the referred clinician
This project used Clinical
Redesign Methodology
Only 20% positive
experience
A new care coordination model was developed which included:
• Daily MDT meetings at the electronic patient journey board (ePJB),
• Development and updating of EDD’s during ePJB meetings,
• Form to document MDT ePJB meetings, • Computer on wheels for ward rounds, • Entering of referrals in ‘real time’, • Structured post intake ward rounds (medicine &
nurse participation), agreed start time & completion of safety checklist on round,
• Structured interdisciplinary bedside rounds (SIBR) incorporating a safety checklist within a MDT care plan,
• Structured communication scripts to improve team efficiency
Root cause analysis was conducted for each issue
Cassandra Davis: Respiratory CNC Andrea Davis: Social Worker Nai-Lan Grant: Physiotherapy Head of Department Chris Colmer Physiotherapist Suzanne Payne: ISLHD Clinical Redesign Coordinator
0%
20%
40%
60%
80%
100%
0
5
10
15
20
25
30
35
40
ADRAincomplete
No teamprocess
No time onrounds
Criteria notvisible
Coun
t
Referral Processes Root Causes
0%
20%
40%
60%
80%
100%
05
101520253035404550
No MDTmeeting
No MDT CarePlan
No pagerssome allied
health
Coun
t
MDT Communication Root Causes
0%
20%
40%
60%
80%
100%
02468
101214161820
Not inhandoverprocess
Info notvalued
Family notincluded
Staff don’t call
interpreter
Coun
t
ADRA Root Causes
Repeat patient / carer stories (n=9) identified significant improvements in care coordination as well as improvements in information, transition
and emotional support..
Documentation of EDDs
improved.
60%
40%
% Referrals with Delays (n=70) April-May 2014
No DelayDelay
Target 44% Objective exceeded
Target 70% Objective Exceeded
Referral process became well controlled - median time of referral (medical record to eMR) fell from 6hrs to14minutes.
E A AE
E E EH
EH
EFH
EFH
EFH
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F EF
EF
A BG
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AG
G G G G G G G
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25/0
4/20
14
29/0
4/20
14
29/0
4/20
14
30/0
4/20
14
1/05
/201
4
6/05
/201
4
9/05
/201
4
13/0
5/20
14
16/0
5/20
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9/06
/201
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16/0
6/20
14
24/0
6/20
14
28/0
1/20
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30/0
1/20
15
3/02
/201
5
3/02
/201
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5/02
/201
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5/02
/201
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/201
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/201
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11/0
2/20
15
13/0
2/20
15
17/0
2/20
15
19/0
2/20
15
20/0
2/20
15
23/0
2/20
15
24/0
2/20
15
25/0
2/20
15
27/0
2/20
15
3/03
/201
5
15/0
3/20
15
27/0
3/20
15
27/0
3/20
15
6/04
/201
5
Special Cause Flag
Min
utes
Period
Time (mins) from Allied Health Request in Medical Record to eMR Request
PRE: Median 6hrs
POST: Median 14 min
Additional Benefits The Post Intake Checklist improved patient safety and documentation: • Removal rates of IVC’s not in use increased by
83% [Control (n=12): 17%, Intervention (n=11): 100%]
• IVC dwell time reduced by 1 day [Control (n=13): median 2 days, Intervention (n=11): median < 1 day].
• Documentation of an ‘IVC removal plan’ increased by 32% [Control (n=26): 8%, Intervention (n=26): 42%].
• Documentation of end of life care plans was 64% higher [Control (n=30): 3%, Intervention (n=30): 67%]
• Rates of DVT prophylaxis were 25% higher in the Post Intake Ward round group [Control (n=30): 42%, Intervention (n=30):67%].
“The coordination of my care was excellent. There is only one word for it…..excellent” Charlie (Patient)
“It was excellent, I got to hear what everyone had to say and tell them what Dad is normally like at home.
I also know he will be discharged home tomorrow and I can prepare for that.” Daisy, Carer
“It truly was…. It was one of the best hospital experiences we’ve ever had…and we’ve had a
few. You don’t really expect ….you’re expectations aren’t great of the environment or the people or any of that because everybody’s
just doing their job and you sort of sit in the corner and let them do it. But this was much
more inclusive. More friendly and more personable. It was just better.”
Susie, Carer
“Overall, it [new care coordination model] has just made medical respiratory unit a better communication hub...and I think just among staff everyone just communicates better. Tom, Physio
Staff experience improved
0%
20%
40%
60%
80%
100%
TCRA <24hrs
Referral if+TCRA
ADRAcompleted
<24hrs
EDDDocumented
60%
50%
23%
36%
79% 70% 66%
100%
Admission Discharge Risk Assessment (ADRA)
(n=70 Pre & Post)
Pre Post
Completion rates and MDT referral
from ADRA improved.