INTERDISCIPLINARY ROUNDS ON MEDICAL UNITS. Kim Salee MSN, RN, AGCNS-BC, CWOCN Mary Moll MSN, RN, CMSRN, NEA-BC

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1 INTERDISCIPLINARY ROUNDS ON MEDICAL UNITS Kim Salee MSN, RN, AGCNS-BC, CWOCN Mary Moll MSN, RN, CMSRN, NEA-BC

2 OBJECTIVES Describe one benefit of Interdisciplinary Rounds Describe the impact Interdisciplinary Rounds are having on quality of care and patient safety

3 ST. MARY S MEDICAL CENTER St. Vincent s Indiana/Ascension Health System Magnet Designation 2011 & licensed beds 18,576 Inpatient admissions 332,971 Outpatient visits 51,649 Emergency Department visits 54% BSN 46% Certified RNs

4 BACKGROUND Executive Director attended presentation by Kennestone Regional Medical Center on Interdisciplinary Rounds at AONE conference April 2014 Hospitalist Champion, CNS and Case Manager had initiated Interdisciplinary Rounds in the Medical ICU at St. Mary s January 2014 Organization support for expanding Interdisciplinary Rounds to additional nursing units

5 ISSUE/ PROBLEM STATEMENT High patient acuity and complexity requires a multidisciplinary team effort to address patient care needs. Current process lacks structure and consistent team members, creating rework and inefficiency. This results in increased length of stay (FY14 O/E 1.16) and increased cost per case (FY14 O/E 1.04), increasing hospital costs by more than $350,000 per year on the medical pulmonary unit

6 Background/ Measurement FY2014 Pulmonary Medical Unit hospitalist attending total cases: 1,049 (87% of total) Arithmetic Cost/Case Observed: $9, 186 Expected: $8, 844 Arithmetic Length of Stay Observed: 4.85 Expected: 4.19

7 TEAM MEMBERS Hospitalists- Gather information and summarize plan of care for the day and identify needs for discharge Clinical Nurses- Discuss patient progress, any concerns from previous 24 hours, bring forward patient input to the team and review team discussion with the patient following IDRs Pharmacists- Discuss and enter medication orders (IV to PO conversion), monitor therapeutic levels, antibiotic stewardship, ensure DVT and GI prophylaxis Therapy- Coordinate early mobilization and identify patient limitations and needs for safe discharge Case Management- Coordinate discharge needs and ensure patient transition to appropriate/ safe discharge environment

8 TEAM MEMBERS CNS- coordinate the team and enter orders real-time to avoid delays in care, provide coaching and feedback to clinical nurses Clinical Supervisor- Ensure timely progression through IDRs (time keeper), enter orders real-time to avoid delays in care, provide coaching and feedback to clinical nurses Dieticians- Address nutritional needs for high risk patients, modify diets for renal failure, heart failure and diabetes Palliative Care- Identify patients who would benefit from additional support services Pastoral Care- Provide spiritual and emotional support to both patients and care team

9 GOAL By November 2014 we will develop and implement an interdisciplinary rounding model which improves communication/coordination and eliminates inefficiency and rework. We expect to see a decrease in LOS and cost per case by June 2015.

10 CURRENT CONDITION Limited attendance Subjective concerns Missed quality improvement opportunities Results in some missed opportunities Daily patient huddle RN gives update on patient Discharge Planning Recommendations made Patient discharged Case Management/ Social Worker hunts down physician for any forms that need signed RN contacts Physician for orders Patient discharged with missed quality and safety opportunities Delays in transition at discharge Physicians often paged multiple times by multiple caregivers

11 ROOT CAUSE ANALYSIS Our patients are discharged with missed quality and safety opportunities WHY? Patient care is focused on discipline specific priorities WHY? Our complex Electronic Health Record (EHR) and limited resources make it difficult for individual disciplines to search out pertinent interdisciplinary information needed for more comprehensive patient care. WHY DO CAREGIVERS NOT COMMUNICATE THIS VITAL INFORMATION DIRECTLY WITH EACH OTHER? It is nearly impossible to coordinate availability with the multiple disciplines each nurse needs to talk to in order to improve patient care. WHY DON T WE HAVE A CONSISTENT, STRUCTURED PROCESS TO MEET THIS NEED? Limited resources (knowledge, time, personnel, tools)

12 TARGET CONDITION Attended by all Interdisciplinary Team members Opportunities don t get missed No delays in care Decreased LOS Interdisciplinary Rounds Checklist driven agenda Orders entered and forms signed at rounds Plan for next day discharges Discharge Leadership rounding RN updates patient on Plan of Care Validates patient involved in POC Improved communication and patient satisfaction

13 COUNTERMEASURE Develop and implement a structured process to be followed in all interdisciplinary rounds

14 Interdisciplinary Rounds Checklist CNS/Clinical Supervisor Enters verbal orders Facilitates participation/ Collaborates with nursing Nursing 2-3 min Pharmacy <1 min Case Management Code Status/ POA Patient presentation/ Review of systems Specific content for each system Antibiotic use/need Culture status VTE prophylaxis Facilitates transitions Insurance/Social DME orders Pain PUD prophylaxis Discharge needs/barriers Mobility Steroid use/need PT/OT needs VTE prophylaxis IV/PO readiness IHI risk score Home med issues Respiratory Therapy <1 min O2 needs Respiratory treatments Dietary < 1 min Nutrition status Nutrition treatments Physical Therapy <1min PT/OT needs Activity level Mobility category Physician 1-2 min Anticipated d/c date Anticipated d/c location Plan of care Palliative Care needs

15 ACTION PLAN What Who By When Modify ICU checklist Team 11/4/2014 Set schedule and attendance for Interdisciplinary Rounds (IDR) Team 11/4/2014 Define participant roles Team 11/4/2014 Educate and engage RNs Educate and engage physicians Exec Director, Director, Clinical Supervisors, CNS 11/4/2014 Hospitalist Champion 11/4/2014 Conduct mock rounds Team 11/5/2014 & 11/7/2014 Go-live Team 11/24/2014

16 ACT/ ADJUST In April, 2015 staff meetings were held to increase understanding of IDR and participation of all clinical nurses on all shifts and to identify barriers to this process. In addition, we began working more closely with physicians to clarify expectations. Nurses need daily coaching and affirmation IDRs work best when there is a consistent leader Physicians must be actively engaged and encourage use of the checklist Start on time and have a defined ending time

17 OVERCOMING BARRIERS Physician engagement Checklist utilization Environment Patients split between multiple hospitalists Pharmacist needs to have a computer Time requirement for all participants

18 PLANNED VS. ACTUAL RESULTS: 6 SOUTH (PULMONARY) FY2014 FY2015 FY2016 Hospitalist Attending Total Cases Hospitalist Attending % of Total Cases 87% 91% 93% Arithmetic Cost/Case Observed $9,186 $7,562 $7,941 Arithmetic Cost/Case Expected $8,844 $8,593 $9,481 Arithmetic LOS Observed Arithmetic LOS Expected Savings -$358,758 $1,976,427 $2,550,240

19 Observed /Expected Ratio IDR began Updated South Interdisciplinary Rounding Scorecard - Outcomes FY2014 FY2015 FY2016 FYTD Hospitalist Attending Arithmetic Cost/Case O/E Hospitalist Attending Arithmetic LOS O/E Hospitalist Attending Geometric LOS O/E Hospitalist Attending Mortality O/E

20 Per Cent Who Answer "Always" IDR began Updated South Interdisciplinary Rounding - Doctors HCAHPS FY2014 FY2015 FY2016 FYTD2017 Achievement Threshold 75th Percentile Benchmark 90th Percentile HCAHPS Overall Rating Communication with Doctors OVERALL Communication with Doctors RESPECT Communication with DoctorsCommunication with Doctors LISTEN EXPLAIN

21 Per Cent Who Answer "Always" IDR began Updated South Interdisciplinary Rounding Scorecard - Nurses HCAHPS FY2014 FY2015 FY2016 FYTD2017 Achievement Threshold 75th Percentile Benchmark 90th Percentile HCAHPS Overall Rating Communication with Nurses OVERALL Communication with Nurses RESPECT Communication with Nurses Communication with Nurses LISTEN EXPLAIN

22 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Clinical Outcomes 6 6S (Medical Pulmonary) CLABSI rate/ 1000 catheter days 5 4 6S IDR begins 11/ S (Medical Pulmonary) CLABSI rate/ 1000 catheter days 2 1 0

23 Clinical Outcomes 16 6S (Medical Pulmonary) CAUTI rate/ 1000 patient days S IDR begins 11/ S (Medical Pulmonary) CAUTI rate/ 1000 patient days 4 2 0

24 ACT/ ADJUST Continue to support this process and expand unit by unit July Roll out to 6 West Renal Diabetes October Roll out to 4 West ICU Stepdown November Roll out to 2 West Pulmonary Medical January Roll out to 5 Central Cardiology February Roll out to CVICU July Roll out to 6E Oncology Medical July Roll out to 5E Oncology Medical Commitment from Leadership- Directors to attend rounds at least 2 days per week Consistency with physicians SBAR handoff report reorganization Monthly meetings with Interdisciplinary Team for ongoing process improvement Ongoing education/coaching- videotape of what right looks like

25 PLANNED VS. ACTUAL RESULTS: 6 WEST (RENAL) FY2015 FY2016 Hospitalist Attending Total Cases Hospitalist Attending % of Total Cases 76% 77% Arithmetic Cost/Case Observed $10,061 $8,827 Arithmetic Cost/Case Expected $9,164 $9,662 Arithmetic LOS Observed Arithmetic LOS Expected Savings -$757,068 $809,950

26 Observed /Expected Ratio IDR began update West Interdisciplinary Rounding Scorecard - Outcomes FY2015 FY2016 FYTD Hospitalist Attending Arithmetic Cost/Case O/E Hospitalist Attending Arithmetic LOS O/E Hospitalist Attending Geometric LOS O/E Hospitalist Attending Mortality O/E

27 Per Cent Who Answer "Always" IDR began update West Interdisciplinary Rounding Scorecard - Doctor HCAHPS FY2015 FY2016 FY2017 Achievement Threshold 75th Percentile Benchmark 90th Percentile HCAHPS Overall Rating Communication with Doctors OVERALL Communication with Doctors RESPECT Communication with Doctors LISTEN Communication with Doctors EXPLAIN

28 Per Cent Who Answer "Always" IDR began update West Interdisciplinary Rounding Scorecard - Nurse HCAHPS FY2015 FY2016 FY2017 Achievement Threshold 75th Percentile Benchmark 90th Percentile HCAHPS Overall Rating Communication with Nurses OVERALL Communication with Nurses RESPECT Communication with Nurses LISTEN Communication with Nurses EXPLAIN

29 Clinical Outcomes 2.5 6W (Medical Renal) CLABSI rate/ 1000 catheter days W IDR begins 07/ W (Medical Renal) CLABSI rate/ 1000 catheter days 0.5 0

30 Clinical Outcomes 7 6W (Medical Renal) CAUTI rate/ 1000 patient days 6 5 6W IDR begins 07/ W (Medical Renal) CAUTI rate/ 1000 patient days 2 1 0

31 IMPLICATIONS FOR PRACTICE IDRs build professional relationships between RNs, physicians, and ancillary staff creating a healthier work environment RNs develop enhanced skills in assessment, case presentation and analysis IDRs lead to efficient patient-centered care with a multidisciplinary Plan of Care which leads to improved clinical and financial outcomes

32 REFERENCES Begue, A., Overcash, J., Lewis, R., Blanchard, S., Askew, T. M., Borden, C. P., Semos, T., Yagodich, A. D., & Ross, P. R. (2012). Retrospective study of multidisciplinary rounding on a thoracic surgical oncology unit. Clinical Journal of Oncology Nursing, 16(6), Cornell, P., & Townsend-Gervis, M. 2014). Improving situation awareness and patient outcomes through interdisciplinary rounding and structured communication. The Journal of Nursing Administration, 44(3), Henneman, E. A., Kleppel, R., & Hinchey, K. T. (2013). Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds. The Journal of Nursing Administration, 43(5),

33 REFERENCES (CONTINUED) Menefee, K. S. (2014). The Menefee model for patient-focused interdisciplinary team collaboration. The Journal of Nursing Administration, 44(11), Reimer, N. (2014). Round and round we go: Rounding strategies to impact exemplary professional practice. Clinical Journal of Oncology Nursing. Rimmerman, C. M. (2013). Establishing patient-centered physician and nurse bedside rounding. PEJ, Sullivan, M., Kiovsky, R. D., Mason, D. J., Hill, C. D., & Dukes, C. (2015). Interprofessional collaboration and education. AJN, 115(3),

34 QUESTIONS?