ma Ready to Go! Patient-Centered Discharge Process Improvement Sherrie Karleskind, BSN, RN-C-Maternal Newborn Nursing El Camino Hospital, Mountain View, CA October, 25, 2013
It s 3 pm Does this look familiar to you? 2
So many reasons.. MD visited but didn t write discharge order MD will visit, but not until after office hours MD told the patient to Go ahead and stay until 6pm Labs aren t done Patient wanted to stay for lunch/dinner Patient sleeping, showering, packing at discharge time Visitors arrive at discharge time Patient s ride is late, working or had to run an errand Patient wants to stay through next medication so no need to rush to pharmacy Left the car seat at home Left the car seat instructions at home One more feeding before discharge And so on 3
Background 54- bed Mother-Baby unit Average daily discharges 12 mother-baby couplets (24 patients) Discharge time has become later and later, despite a stated 11 a.m. discharge time Later discharges result in new patients waiting for beds in L&D or being put in double rooms, leading to dissatisfaction Predicting staffing for the evening shift difficult 4
Discharge Improvement Team Fatima Garcia, EVS Sherrie Karleskind, RN MBU Wendy Kenney, RN L&D Fe-Anne Lopez, RN MBU Sophia Palaad, RN MBU Linda Warner, RN MBU Shana Padgett, Facilitator 5
Staff Perspective Nurses felt some patients were slow and disorganized and that they were not following directions Our care partners are frustrated when customers were not ready for planned process steps (birth recorder, lab) Nurses felt uncomfortable pushing customers out when all preparations were complete Nurses feared customers would be dissatisfied and leave with a negative last impression 6
Patient Perspective Our patients reported feel rushed and unprepared on their day of discharge Our patients felt that their questions weren t always fully resolved Our patients expressed dissatisfaction with our current discharge process and did not feel that they were part of the plan 7
Our Goal! Increase staff and patient satisfaction with the discharge process Standardize preparation/education for discharge to increase customer confidence and knowledge at discharge Establish a discharge criterion of 11am to more effectively use resources across the continuum of care in Maternal Child Services 8
How We Designed a Better Way Identified the need Created cross-functional team of front-line caregivers to work through the issues Used Lean Principles Talked to our customers, both patients and staff Innovated new approaches and piloted them Incorporated staff and patient feedback and into the next design 9
Lean Thinking Value in the eyes of the customer Flow, Flow, Flow Pull vs. Push Elimination of waste Respect for people Standardization of what is routine, repeatable &definable Continuous improvement through standardization & stabilization Pursuit of Perfection 10
In Partnership with L&D NICU EVS Nutrition Notary Birth Recorder Volunteers Physicians Leadership Performance Improvement Information Technology Each other, across shifts and through differences of opinion 11
Key Problem #1 Problem: Varying practices among staff in how the key messages for discharge are communicated. Why: There isn t discharge standard work, standard training or an audit for success. What we did: Standardized discharge plan starting with admit to L&D through to discharge from MBU. Standardized teaching, timing and key messages across all staff. All Mother Baby staff received same training, including observation and return demonstration. 12
Key Problem #2 Problem: Nurse feedback is that patients are not compliant with discharge expectations. Patients voiced they were not aware of the process Why: Patients are not involved/informed of the process What we did: We implemented the Perfect White Board Engages the patient and keeps them informed. 13
So, how did we get there? 14
Summary of Changes Made Assessment of vaccine status begins on admission to L&D and documented in EMR prevents vaccines from being given at discharge Standardized messaging from all staff, including physicians: Discharge time is by 11 am Perfect Whiteboard helps staff and patients track progress to discharge. Patients offered a choice of discharge times: 9, 10 or 11 am 15
Summary of Changes Made Home care teaching tracked on Plan of Care. Standardized Home Care Instructions for mom and newborn completed on day before discharge, includes using teach back MD driven discharge instructions given at discharge (almost identical to Home Care Instructions) Teach back method used to determine patient s understanding of previous instructions 16
How We Worked Together 17
Outcomes 18
Outcomes 19
Trending Up! % Patients Discharged by 12:00 Noon 20
Voice of our Customers Today Parents of a 2-week old that were recently interviewed shared how supported and prepared they felt when they checked out. We loved the home care sheet in the packet and I (Dad) still pull that sheet out about once a day! Our patients love The Perfect Whiteboard. They know what is next and are part of the plan. (verbatims, interviews & rounding) Care partners are excited and thankful for how prepared the parents are to participate in shared processes. (notary, birth recorder, lab) One set of parents loved new whiteboard so much that they brought in their friends (who had delivered at another hospital) to show them the process. (rounding) 21
And, how will we stay on top? 22
Control & Sustain, and Improve Daily Metrics Daily Huddle at Pit Crew Expectations managed with patient and staff Audits & Rounding HCAHPS responses Discharge Tracker logged daily to develop Pareto around barriers to success. 23
Lessons Learned Change can be hard. Our assumptions are not always proven to be fact (i.e., patients don t want to go home, or that they want to stay for lunch). Standardizing 4 areas of work across 2 departments and standardizing key messages across 3 units IS NO SMALL TASK. Newly implemented daily metrics can be exciting and a little intimidating. Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead 24
Thank You! 25
Questions? 26