TL3EO: The CNO influences organization-wide change beyond the scope of nursing.

Transcription

1 Transformational Leadership: Advocacy and Influence TL3EO: The CNO influences organization-wide change beyond the scope of nursing. TL3EOa Provide one example, with supporting evidence, of a CNO-influenced positive change that had organization-wide impact beyond the scope of nursing services. Background/Problem(s) Optimizing Patient Flow is a hospital wide, strategic initiative that aims to improve access, care delivery, and patient progression, while maintaining optimal quality, safety, and service. MGH functions at high capacity each day and this may limit optimal patient placement, impede patient progression, delay timely discharge, and limit the MGH s ability to accommodate additional patient volume. Jeanette Ives Erickson, RN, DNP, FAAN, NEA-BC, Senior Vice President for Patient Care and Chief Nurse, co-led the Optimizing Patient Flow strategic initiative with Michael R. Jaff, DO, Paul and Phyllis Fireman Chair in Vascular Medicine and Medical Director, Fireman Vascular Center. They prepared and presented the Optimizing Patient Flow Care Delivery and Patient Progression framework to the MGH General Executive Committee (GEC) in April 2014 and received approval to proceed with implementation. The Patient Progression Improvement Team co-chaired by Ives Erickson and Jaff was launched on August 4, 2014 and met on a weekly basis throughout The team s initial focus was to develop and implement efforts designed to eliminate identified system issues that limit patient placement and delay timely discharges in order to improve efficiency and increase capacity to provide inpatient care to patients who need it. The Patient Progression Improvement Team membership included nursing and physician leaders from the Neurosciences, Medicine, and Surgery, as well representatives from Case Management, Social Services, Physical Therapy, Process Improvement, and Service Excellence. The Patient Progression Improvement Team developed and monitored action plans, held teams accountable, and reviewed relevant data in order to achieve the objective of ensuring that patients receive the right care in the right place, and at the right time. Status of key initiatives, including barriers and facilitators, were reported weekly to Ives Erickson and Jaff. The initiatives and outcomes of the Patient Progression Improvement Team were brought forward by Ives Erickson and Jaff through bi-monthly presentations to Service Chiefs. In addition, Ives Erickson, Jaff, and Peter Slavin, MD, President of the Massachusetts General Hospital, updated the GEC on a bimonthly basis. The Neurosciences (Neurology and Neurosurgery) were selected as an initial focus of the team s work based on the potential to decrease excess inpatient bed days and reduce average length of hospital stay. The Neurosciences accounted for nearly 30,000

2 bed days in Fiscal Year 2014, the year the Optimizing Patient Flow initiative was launched. The goals, initiatives, and outcomes outlined below focus on the team initiatives in the Neurosciences. Goal Statement(s) Average length of stay is a key metric of the Patient Progression Improvement Team initiatives. Average length of stay is a standard measure of throughput, volume, and efficiency that is reported routinely by the MGH Budget Office. Average Length of Stay in the Neurosciences was reported between 5.5 and 6.0 days and increasing over time prior to The Patient Progression Improvement Team s goal was to reduce neuroscience patients average length of hospital stay. The average length of stay for patients discharged from the Neurosciences between January and March 2014 was 5.3 days. Key Intervention(s)/Initiative(s)/Activity(ies) A number of key initiatives designed to engage leaders and staff, improve processes and measure outcomes were identified in 2014 through the Patient Progression Improvement Team work led by Ives Erickson and Jaff. Although each initiative had their own goals and objectives, all were thought to have an impact on patients overall length of stay. A timeline outlining the initiatives is presented below.

3 Neurology Interdisciplinary Rounding The Neurology Inpatient Rounds Improvements Taskforce, an interdisciplinary workgroup, was formed in May 2014 in the Department of Neurology to improve the Interdisciplinary Rounding process. This workgroup aimed to enhance the rounding process with a focus on improving patient care, communication and visibility, while fostering collaboration between the care team disciplines. The critical components of the process changes were: Add early morning rounding in addition to rounds held at 1:30 pm to expedite early discharge of patients who are ready for next level of care Improve the efficiency of rounding process by using a checklist to focus the discussion on overnight events, orders and plans Encourage attendance and representation of all disciplines/ provider teams Develop and review the plan for the day for all patients at rounds The implementation of this work resulted in an improvement in patient progression measured by an increase in the number of patients discharged before noon. The increase in pre-noon discharges has been sustained over time. Guardianship Program Every day, the hospital cares for patients who require guardianship. Though small in number, these patients historically have had a significant impact on length of stay, particularly in the neurosciences. In August 2014, a pilot program to address guardianship was established in the Neurosciences to reduce avoidable days related to the guardianship process and minimize administrative burden on clinical teams. An additional objective of this pilot was to understand the clinical, social, and other factors contributing to longer length of stay among guardianship patients. The key components of the pilot were: Maximize effectiveness of Social Services resources Pilot the addition of an Advanced Practice Nurse as part of the team Add project management resources to design and measure effectiveness This work resulted in expedited identification of complex cases and more efficient administration of the guardianship process, as well as advocating for our patients safe discharge to the next level of care. The overall length of time to process guardianship cases internally has been minimized and the overall average length of stay of guardianship patients has decreased. In addition, the care team has had success in working with families to assist patients in appointing a Health Care Proxy (HCP) or locating a pre-existing HCP, which has helped to avert guardianship for many potential cases.

4 Neurosurgery Risk Assessment Predictive Tool In September 2014, the Department of Neurosurgery developed a Risk Assessment Prediction Tool (RAPT) for patients receiving Neurosurgical spine surgery to assist with predicting discharge destinations and planning for discharge. The RAPT questionnaire, administered by a nurse, contained key questions about the patients current mobility, ability to perform basic self care, current pain level and medications as well as whether they had experienced a fall and their pre-hospitalization living situation. Results showed aggregate scores predicted with reasonable accuracy whether a patient went home with or without services or to rehab facility. Pre-surgery patient education was determined to be essential to this process as it presented an opportunity to clarify expectations regarding anticipated length of stay, pain management and discharge plan including an expected post acute level of care. Neurosurgeon and nursing involvement is the foundation of this education and includes a review of any additional surgery instructions. This work resulted in a decreased length of stay for the spine surgery population by as much as half a day. Early AM Discharge Pilot Since September 2014, the Neurosciences have been working on the first phase of the Early AM Discharge Pilot. The project s goal was to ensure discharge to home before 10am (if appropriate) of one neurosurgery and two neurology patients from either Lunder 7 or Lunder 8. The basis for this change was mathematical modeling performed early in 2014 by representatives from the Massachusetts Institute of Technology that showed discharging patients earlier will assist in the reduction of patient wait times for admission to Neurology units from the Post Anesthesia Care Unit, Emergency Department and the Neuroscience Intensive Care Unit.

5 Outcomes of this work showed an increase in the percentage of identified early AM neurology and neurosurgery patients discharged before 10 AM and a decrease in the neurology and neurosurgery patient average time of first discharge of day. Estimated Date of Discharge Tool In December 2014, a new on-line tool was implemented to assure documentation and communication of Estimated Discharge Date (EDD) among all members of the interdisciplinary team. The tool provided real-time access to updates on the estimated date of discharge, the expected discharge disposition, barriers to discharges, and status and associated tasks of impending discharges. Because all members of the care team had access and contributed to the information in the tool, communication to the patient and family was more consistent and timely. Utilization statistics were posted on the Length of Stay portal page, an internal repository of resources and data, and the Neurosciences were among earliest adopters with the highest levels of utilization. Continued focus on communication and awareness among the care team as well as patients and families regarding estimated date of discharge may have contributed to a shorter overall length of stay in the Neurosciences.

6 Post Acute Levels of Care Education All members of the healthcare team, including patients and families, need to have a working understanding of the levels of post-acute care to ensure patients needs are fully met after discharge and to facilitate patient progression. Post acute care choices should be based on: individual patient needs plans for ongoing treatment input from the team, family, and patient availability of care options insurance considerations A discharge plan that places the patient in the most appropriate care setting can vastly affect clinical outcomes and minimize the possibility of readmission. Understanding

7 what level of post acute care best meets patients care needs is critical to patient progression. Toward this end, an interdisciplinary MGH team created a series of educational materials clearly delineating the various levels of post-acute care according to Medicare guidelines. These materials were distributed to staff and to patients and family members during discharge planning. The ultimate goal was to determine the placement locations that are most appropriate and best suited to meet the needs of our patients and families. Posters, tip cards, interdisciplinary grand rounds, and departmental presentations were rolled out in December 2014 through February 2015.

8 Participants Patient Progression Improvement Team Name/Credential Title Department/Unit Jeanette Ives Erickson, RN, DNP, FAAN, NEA-BC Senior Vice President and Chief Nursing Officer Nursing & Patient Care Services Co-Chair Michael R. Jaff, DO Medical Director Vascular Center Co-Chair Brit Nicholson, MD Senior Vice President and Department of Medicine Chief Medical Officer Paul Simmons, MD Assistant Chief Medical Case Management Officer Nancy Sullivan Executive Director Case Management Marie Elena Gioiella, Director Social Service Department LICSW Michael Sullivan, DPT, PT Director Physical Therapy Services OT Marianne Ditomassi, RN, DNP, MBA, NEA-BC Executive Director Nursing & Patient Care Services Operations Mary Cramer Senior Director Process Improvement and Ambulatory Management and Performance Rick Evans Chief Experience Officer Service Excellence Amy Giuliano Senior Project Manager Nursing & Patient Care Services Administration Meridale Baggett, MD Physician Department of Medicine Walter O Donnell, MD Medical Director Inpatient Medical Service Theresa Gallivan, RN Associate Chief Nurse, Medical, Heart Center and Emergency Nursing Nursing & Patient Care Services Rhodes Berube Administrative Director for Department of Medicine Operations Lee Schwamm, MD Executive Vice Chairman Department of Neurology Adam Cohen, MD Inpatient Medical Director Department of Neurology Kevin Whitney, RN, DNP Associate Chief Nurse, Surgery, Ortho, Neurosciences Patient Care Services Brooke Swearingen, MD Physician Department of Neurosurgery Kim Wilbur Executive Director Department of Neurology Ron Ash Administrative Director Department of Neurosurgery Matt Hutter, MD Assistant in Surgery Department of Surgery Cam Wright, MD Physician Department of Surgery Liz Lancaster Executive Director Department of Surgery Donna Antonelli Manager Department of Surgery

9 Outcomes Measurement is a key component of the Patient Progression Improvement work. A weekly dashboard was established to monitor length of stay, the percentage of discharges before 10am, key volume statistics, and, since a significant proportion of our patients is admitted through the emergency department (ED), delays in ED patients getting placed in a bed. Potentially avoidable days are monitored routinely by measuring the excess days when benchmarking our patients with patients of similar diagnostic and demographic characteristics as those of other national academic medical centers. Average length of stay is measured by analyzing the population of Neuroscience patients discharged during each quarter. The chart below shows that average length of stay (ALOS) in the Neurosciences was reduced from 5.3 ALOS pre-intervention to a range of 4.5 to 5.0 ALOS post-intervention of the neuroscience specific initiatives.