Discharge Before Noon DH32

Transcription

1 Discharge Before Noon DH32 Green Belts: Champion: Susan Christensen, RN Eric Belen Hai Tran Alice Issai Date: March 21,

2 DEFINE Problem Statement 1. Baseline data shows only 18% of patient discharges* happen before 12:00 PM for elective Orthopaedic cases. 2. It takes an average of 3 42 (or 222 minutes) from when discharge orders are entered to when patient is discharged. This causes backlog in patient admission, delay in care, harm to patient safety & patient dissatisfaction. *Baseline Data: 143 elective cases discharged from July 2010 to December

3 DEFINE 3

4 DEFINE SIPOC Will be discussed in detail in Cause & Effect Summary 4

5 DEFINE Stakeholder Analysis Stakeholder Analysis Stakeholder(s) Level of Influence Interest in project 2 Current Level of Support Strategy Likert 1-5 High = 3 Medium = 2 Low = 1 Gain = 3 Neutral = 2 Loss = 1 Very supportive = 5 Slightly Supportive =4 Neutral = 3 Slightly Resistant =2 Very Resistant = 1 Dr. Ranjan Gupta - Chair Acquired Dr. Samuel Bederman Acquired Terry Donly, RN - Nurse Manage Acquired Tina Moeller, RN - Case Mgr Acquired PT/OT Help from Dept Heads Pre-Op & Clinical Schedulers Help from Dept Heads Pharmacy Help from Dept Heads Staff RN Help from Dept Heads Residents Help from Dept Heads Stakeholder Analysis shows everyone has buy-in into the project! 5

6 DEFINE Early Waste Identification DOMOWIT MUDA Identified Defects: Pregnant phlebotomists refuse to draw labs on patients in Contact Isolation Lack of communication regarding discharge plan & barriers with bedside RN OP Pharmacy does not have access to patient financials info Over-production: Motion: Team has to travel to Imaging as there is no PACS viewer on DH32 Patient/family return to pick up scripts if not renewed in post-op clinic visit Over-processing: Case Managers having to print notes and place in patient chart because they are not in Quest Waiting: Not adequate pain medication prior to physical therapy Waiting for scripts to be sent to pharmacy on day of discharge Inventory: Transportation: 6

7 DEFINE Going to the Gemba Case Manager CASE MANAGEMENT OBSERVATIONS MARCH 25, MINUTES minutes or 57% of the time is spent on Chart Reviews CHART UR REVIEW & DOCUMENTATION CM/ CSW MD PATIENT FAMILY PCC RN THERAPY TRAVEL ACTIVITY *Excluded personal counteractions with observer No personal time or breaks observed Case Manager assigned to DH32, aside from seeing Orthopaedic patients, are assigned to 4 other different Units and different Services 7

8 DEFINE Voice of Customer (VOC) 10 English speaking patients interviewed both Ortho & Colorectal Elective surgeries Question: What are the most important actions we need to take care of for you to feel safe and ready to discharge? Themes Count %. 1. Knowing time of DC 4 25% 2. Transportation Home 3 19% 3. Safe Ambulation 3 19% 4. Constipation 2 13% 5. Pain Control 2 13% 6. Financial concerns 1 6% 7. Hygiene 1 6% 44% relates to patient Knowing time of DC and Transport Home 32% relates to Ambulation and Pain Control paste 8

9 DEFINE Process Flow Swim Lanes START paste END 9

10 MEASURE Baseline Data DCs continue from 6AM to 6PM DC lead time tends to shorten towards the end of the day paste 10

11 MEASURE Baseline Data DC orders written peak at 12PM Target time of actual DC DCs peak at 3PM paste peak of patient admissions 11

12 MEASURE Baseline Data for Y Baseline data for discharge percentage was based on 143 elective Orthopaedic cases from July 2010 to December Performance Measure Operational Definition Data Source and Location Sample Size Who Will Collect the Data When Will Data be Collected How Will Data be Collected Other Data that should be Collected at the same time 1. Time of Patient Discharge 2. Time Discharge Order entered Date/time stamps of when physician order to discharge a patient and date/time patient is actually discharged Quest Reports Month s activity Eric Belen End of the month Quest canned reports Cases to be sorted between electives and trauma (nonelectives) 12

13 MEASURE Stability Process is in control Normality Data is Normal Capability Process is capable 12:00 pm BASELINE Observed shows 17% good 13

14 ANALYZE 1. Ride Home is Late Patient informed too late 12PM Target not clear 2. DC orders written after 12pm Surgeries after morning rounds 3. Team roles and DC process/sop is unclear 14

15 ANALYZE Cause & Effect Summary 44 Inputs were originally identified in the SIPOC These 44 Inputs were then rated within categories Patient Readiness for Discharge MD & Team Prep for Discharge Pt discharged before 12 noon The C & E methodology identified the 15 top Inputs with highest scores as seen in the next slide The 15 top ranked Inputs guided the work of the Kaizen paste 15

16 Cause & Effect ANALYZE Lean Sigma Project Guide.xls paste 16

17 5 Whys ANALYZE Lean Sigma Project Guide.xls paste 17

18 5 Whys ANALYZE 1. Patient not clearly informed of DC time too late 12PM Target not clear 2. Team roles and DC process/sop is unclear 12PM Target not clear paste 18

19 Kaizen Event 19

20 KAIZEN IMPROVE Impediments & Intervention 20

21 Workload Balance KAIZEN IMPROVE 41 % of activities frequently occurred the day of discharge Re-balance of Discharge Tasks Day of DC is task heavy! Tasks on day of DC reduced from 16 tasks to 4 (or by 75%) 21

22 18 KAIZEN IMPROVE Re-balance of Discharge Tasks 16 Tasks % REDUCTION BASELINE IMPROVED Pre-Op Date of Surgery Post-OP Period Date Prior to Discharge Date of Discharge 22

23 KAIZEN IMPROVE Improved Communication: Daily Discharge Rounds & Staff Whiteboard Tina Terry Susan Dr. Cinat Patient Board located in Staff Room, updated everyday Communicates to all concerned status of each patient and expected day of DC 23

24 KAIZEN IMPROVE Improved Communication: Patient Expectations/ Education Room Board OLD Expected Day of DC NEW Tasks to Complete Patient Board located in patient s room, updated daily Visual Aid that helps the staff and involves the patient in his/her care 24

25 Status of Early Muda Identification Defects: Pregnant phlebotomists refuse to draw labs on patients in Contact Isolation (resolved) Lack of communication regarding discharge plan & barriers with bedside RN (resolved) OP Pharmacy does not have access to patient financials info (resolved) Over-production: Motion: Team has to travel to Imaging as there is no PACS viewer on DH32 (resolved) Patient/family return to pick up scripts if not renewed in post-op clinic visit (resolved) Over-processing: Case Managers having to print notes and place in patient chart because they are not in Quest (resolved) Waiting: KAIZEN IMPROVE Waiting for scripts to be sent to pharmacy on day of discharge (WIP scripts written morning of discharge ongoing discussions with physicians) Inventory: Transportation: Not adequate pain medication prior to physical therapy (resolved; staff education module in place) paste 25

26 Right after key interventions implemented, June numbers jump to 30% CONTROL Sept & Oct numbers dip, caused primarily to orders written late DC % steady with both improvement in median order time & discharge leadtime 26

27 Interventions CONTROL 27

28 CONTROL Control Plan to keep Improvements in place Reaction plan/feedback mechanism 28

29 Patient Data Log CONTROL Patient Data Log/Spreadsheet to document reasons for delay and feedback for reaction plan if needed 29

30 Stability Final Capability/Control CONTROL 12:00 pm 12:00 pm Mean of DC Time moved an hour nearer to Target DC Time Process is in control Capability While the distribution became wider, more cases achieved target DC time 12:00 pm BASELINE Observed shows 17% good IMPROVED Observed shows 34.6% good 30

31 Pain Management Scores Added Benefits 7.37 % increase (from 97 respondents) 31

32 Added Benefits Good! Dip primarily caused by change in Supervision 32

33 ED Patient Wait Time for DH32 Admission ED Admission to DH32 (for Bed Request from 9am-1pm) Added Benefits DH32 Bed Confirmation for ED admission has decreased from 2hours to 24minutes ED admission volume has increased from an average of 30 per month to 45 patients (50%) 33