Quality Improvement Project Control Report Out

Transcription

1 Quality Improvement Project Control Report Out Prince County Hospital Surgery Floor Lean Project July 10th, 2014

2 Define Health PEI s ELT ( Executive Leadership Team ) identified the service areas throughout the province for the LEAN projects. The primary focus was to facilitate an overall decreased LOS (length of stay). HPEI Surgery PCH Surgery Staffed Beds Occ Rate 82.0% 93.4% Budgeted Beds Average Daily Census ALC Avg Pts Per Day % Pts ALC 1.9% 2.0% Daily Num Pts Medically Discharged ALOS (Acute Days) Total Length of Stay (Days) ELOS (Days) Re-Admit Rate <= 7 Days 2.5% 2.3% Re-Admit Rate 8 to 28 Days 3.7% 3.4% Intra Transfer Pts Per Day Pts Moved Per Day CI ( Level 2-5) (3 mth rolling average) Avg Med Error Rate (# per month) Pd Hours As % Of Budget Hrs

3 Define Problem Statement Our current process lacks communication, creates duplication, and has undefined roles which results in staff dissatisfaction as identified by feelings of being unsupported. We want to foster a culture of a patient focused, multidisciplinary, collaborative care team which will result in timely referral and discharge processes.

4 Measure The time physio referral is sent to the time the assessment is document. Measure the amount of times the ward clerk is required to do duties off the unit. (ie portering, printer, stores etc.) Number of Times required to answer the phone at the nursing station Time from call requesting bed until time the bed is ready for patient. Including whether completed by bed control or unit environmental services staff. The amount of time Clinical leader spends reviewing and completing narcotic sheets

5 Measure Track the times of Physician arrival on the unit. Track the times the discharges are written, time patient left unit, what service the patient was under. Track the time spent clarify orders Tracking the amount of time spent reporting shift to shift including the hands off and reports between disciplines during the shift. Time spent updating report sheet Track the documentation on the admission history that populates to the discharge summary

6 Analyze There is an average time from physio consult to documentation of 22 hours; this is within the standard, but may be a gap for other health care providers. Overall ward clerks and nurses daily average of time spent off the unit is not as much as previously reported however there is certainly fluctuations related to demands on particular days that can limit patient care hours. Phone calls at the nurses station consistently show higher numbers of calls from other nursing units as opposed to families which was previously thought. Further data analysis might provide more insight into the reason for other nursing units/supervisor calls.

7 Analyze The bed control staff are completing the beds when requested taking an average time of 51 minutes to complete. Housekeeping provided additional support when isolation rooms were identified. On average the clinical leader spends 5 minutes a day reviewing narcotic sheets. Note that time fluctuates with her available time. Physician arrival time on the unit occurs most often in the am with only a few physicians arriving in the afternoon. Discharge order times do not seem to be impacted as the majority of discharge orders are written early in the day. Overall, discharged patients left in a timely manner leaving 99 minutes after discharge order was written.

8 Analyze The amount of time clarifying physician orders was not noted to consume much nursing time as previously thought. The amount of time reporting seems to take up nurse patient hours with the huddles from team members to team leaders taking the most time. Updating the report sheet is another component (tool) of the report process with not all team members using the tool which takes up both nursing and ward clerk time. The service delivery (surgical services ) leads to more rapid turnover and therefore frequent updating. The admissions are mainly completed by the floor staff as opposed to float staff. Elements helpful for discharge planning on the admission assessment and history form are not completed. The discharge planning/education is poorly documented.

9 Improve PDSA 1 Description: Following the physio assessment, Physio does an orderable for nursing when applicable to communicate plan of care. (ie. ambulation order). Following seeing the patient the physiotherapist will initial and check the unit boards indicating the patient was assessed by PT. Date Implemented: June 16 th, 2014

10 Improve PDSA 2 Description: Revise reporting process to do paper reports rather than taped. The written report created will provide a concise standardized process to communicate necessary patient information for direct patient care from shift to shift, as well as act as a working reference tool to replace the current report sheet. Date Implemented: June 16 th, 2014

11 Improve PDSA 3 Description: Assess and streamline documentation to ensure it meets patients care needs. Physio and nursing will use the ongoing discharge planning form to document the functional and home environment assessments. Date Implemented: June 16, 2014

12 Improve PDSA 4 Description: Improve the Documentation of Patient Teaching Date Implemented: June 16 th, 2014

13 Improve Aim statements: 80% of patients will have documented teaching prior to discharge. Reduce overall reporting time for test team by 50% for 24 hours. 80% of functional and home environment assessments will have more than two data elements documented within 24 hours of admission. 90% of all patients will have ambulation orders (when appropriate) entered by physio following assessment of patient.

14 Analyze Time from physio referral to completion of documentation Avg = 37:30

15 % of Patients Analyze % of ambulation orders placed when appropriate 100% 90% 80% Patients with Ambulation Orders 100% 88.9% 70% 60% 50% 40% 30% 20% 10% 0% % Pts with PT Consult % Pts with Ambulation Orders

16 Average Time Analyze Average report times for Green Team Report Times - Green Team 1:12 1:04 0:57 0:50 0:43 0:36 0:28 0:21 0:14 0:07 0:00 T2 Average Total/Day = 3:15 1 Night RN report prep 2 Day Staff receiving report 3 Team members to Team leader 4 Clinical Leader to Team leaders 5 Evening Staff receiving report 6 Day RN report sheet prep 7 Night Staff receive report 8 Team members to Team leader (N) 9 Team leader to 2300 staff T2Average T1 Average

17 Average Time Analyze Average report times for Blue Team Report Times - Blue Team 1:04 0:57 0:50 0:43 0:36 0:28 T2 Average Total/Day = 3:35 1 Night RN report prep 2 Day Staff receiving report 3 Team members to Team leader 4 Clinical Leader to Team leaders 5 Evening Staff receiving report 6 Day RN report sheet prep 7 Night Staff receive report 8 Team members to Team leader (N) 9 Team leader to 2300 staff 0:21 0:14 0:07 0: T2 Average T1 Average

18 Time Each Day Analyze Report sheet prep times for Night RNs Report Sheet Prep Times - Night RN 2:09 1:55 1:40 Range Green = :30-2:00 Blue = :15-2:00 1:26 1:12 0:57 0:43 0:28 Night RN report prep - Green 0:14 Night RN report prep - Blue 0:00 6/16/2014 6/17/2014 6/18/2014 6/19/2014 6/20/2014 6/21/2014 6/22/2014 6/23/2014 6/24/2014 6/25/2014 6/26/2014 6/27/2014 6/28/2014 6/29/2014 6/30/2014

19 Time Each Day Analyze Report sheet prep times for Day RNs Report Sheet Prep Times - Day RN 2:52 2:24 Range Green = :25-2:00 Blue = :10-2:25 Day RN report sheet prep - Green Day RN report sheet prep - Blue 1:55 1:26 0:57 0:28 0:00 6/16/2014 6/17/2014 6/18/2014 6/19/2014 6/20/2014 6/21/2014 6/22/2014 6/23/2014 6/24/2014 6/25/2014 6/26/2014 6/27/2014 6/28/2014 6/29/2014 6/30/2014

20 Discharge summary D/C teaching/instructions (day of D/C) Home environment Functional assessment Patient teaching (prior to D/C) D/C planning assess % of Patients Analyze % Completion of Admission and Discharge tasks Admission & Discharge Tasks 100% 97% 93% 86% 80% 60% 60% 59% 73% Time 1 Time 2 40% 20% 0% 20% 11% 3% 28% 0% 24%

21 Improve Aim statement: 80% of patients will have documented teaching prior to discharge. 28% of patients received teaching prior to discharge which was an improvement from the previous measurement of 3%. Reduce overall reporting time for test team by 50% for 24 hours. Both teams tested written and bedside reporting. No improvement in time lines as numerous issues being worked through.

22 Improve Aim statement: 80% of functional and home environment assessments will have more than two data elements documented within 24 hours of admission. 86% of the patients have a documented home environment while 76% have a documented functional assessment. 90% of all patients will have ambulation orders (when appropriate) entered by physio following assessment of patient. 89% of appropriate patients had ambulation orders.

23 Improve Staff comments and customer feedback on the improvements Ambulation orders from PT are valuable for nursing staff Physio and other Allied Health staff value Discharge planning information; its also useful for nursing on multidisciplinary rounds Informal survey showed that patients and families feel positive about bedside rounding; it helps them know the faces attached to the names on the bedside board It is helpful to have both reports completed by 0800 Some staff struggled and gave negative feedback about the new reporting format/process Written reports are a fundamental change; it takes time to get used to such a big change. Report completion is improving as staff become more familiar Clinical lead values face-to-face time with patients

24 Control What controls have we put in place to ensure that performance does not lapse? Icon taken off downtime computer; staff will not be able to document there in error (IT, Melissa) Ambulation orders will become standard for appropriate patients (Angela) Duplicate or additional report sheets will be removed (Lisa, Melissa and WCs) Storage room has been organized, standardized and colour-coded to reduce risk and save staff time (Lela/WCs, Cheryl) Printer/fax machine is better placed for staff use and efficiency

25 Control What controls have we put in place to ensure that performance does not lapse? Periodic chart audit of documentation (home environment, functional assessment, patient teaching) (Lisa and Melissa) Ongoing education, communication and demonstration to take place around written report process; using s, verbal and written memos/posts (Melissa and SWAT team members) Training and/or demonstration for nursing staff on how to conduct bedside rounds; tip sheet is developed (Melissa) Provide training on documentation and expectations for ward clerk role (Lela, Pam)

26 Sustaining Measures What data should be looked at on an ongoing basis? (6 data points) Physio Ambulation orders (6 x once a month); snapshot of % of appropriate patients with these (second Thu of month) Documentation Chart audits (3 x bi-weekly, 3 x monthly) of home assessment, functional assessment and patient teaching); (second Thu of month) Home environment/functional assessment require 2 data elements within 24 hrs Ensure different teams are audited Snapshot of all patients in surgery beds Reporting Measure report time (for one day-24 hours) x 6 months (second Thu of month)

27 Lessons Learned What were some of the key things we learned about quality improvement while doing this project? Communication is challenging with 24/7 staff Project and PDSA cycle timelines are tight/challenging; need to be attentive and available to project needs Unit leadership team collaborated and communicated well amongst each other Inclusion of other services (Physio and Environmental Services) was a benefit to the team and the project Good planning and communication to impacted services/areas around the changes we are making is important (i.e. IT, Telecommunications, Materials Management) Identifying and addressing staff concerns is important

28 Spread Plan How will we communicate and share our project? The project is a standing agenda item at Nursing Advisory and Nurse Managers meetings Our sponsor/cao continues to update at Medical staff meetings Staff on Restorative unit are requesting written reporting and bedside rounds (starting Monday!!) ICU will be standardizing their Supply Room ICU also propose beginning daily multi-disciplinary rounds (i.e. Pharmacy, PT, RT, Nurse Supervisors), and moving to standardized written/verbal reporting (away from taped report) Physio will spread use of Ambulation Orders to all appropriate patients admitted to PCH Project team will attend Celebration Day

29 Next Steps What is next QI project, next steps or next place the project is spreading? Train floats, nursing supervisors and new staff on the written report and rounding processes Collaborate with CIS in developing electronic reporting tool Communicate with union around resolving staff concerns Identify and resolve individual issues around written reporting process Invite staff to a meeting/discussion Move forward with getting rid of the kardex on Surgery unit Present staff with alternate options for getting kardex information Supply room will receive ongoing reorganization/improvement in collaboration with Material Management

30 The Team!

31 The Team Mascot!