IHI Open School Advanced Case Study Andrea Jewell & Ellen Odai Team: Crazy about IPC The Ottawa Hospital; University of Ottawa IHI Open School Chapter October 14, 2010
Overall process map
What contributed to this adverse event? Communication Breakdowns Chronic Disease Management Emotional/ Social support Communication breakdowns in system; from intake to discharge No integrated communication network across institutions Poor communication between dialysis, radiology, ED, medical unit and primary care physician Poor service at radiology appt- Carla misses the ultrasound Poor system for managing complex chronic diseases Although Carla has been in the system for years, no real treatment plan Lack of a consistent resource to help patients navigate health care system Although Carla had a supportive boss, it was becoming a strain to leave for dialysis Although had emotional support from mother, limited tangible support in the form of rides, financial, or other assistance Resources such as transportation, finances, community support, outpatient nutrition not addressed Poor discharge communication processoverwhelming for Carla Limited patient education provided; importance and urgency of diet and INR not stressed Carla was not empowered to advocate for herself Limited interaction between health and social systems; Carla fell through the cracks Health Care System No trouble shooting guidelines provided; no information on emergency scenarios Poor transitions within the system; Carla has to repeat her history, teach staff her treatment protocol No focus on patient centered care Many obstacles and hurdles; rules are set up for the system and the caregivers Many different facilities and institutions. No consensus for care Organizational Management Poor processes of care; checklists, care maps not used Poor management strategies led employee in radiology to deny appt rather than be patient centered Poor guidelines for managing appointments, tests. No clear protocols Individual Staff Actions Carla s Admission To Nursing Home Importance of ultrasound was not stressed by dialysis nurse to radiology Radiology clerk rescheduled appointment rather than adapt Neither hospital case worker nor social worker follow up on nutrition appointment Medical assistant at dialysis did not check on INR concerns Cursory neurological exam by ED physician Medical student waits for attending physician before reporting concerns regarding mental status
Create rules for the system Simple rules for an ideal health care system: 1. An ideal health care system is one that is comprehensive, organized, flexible and patient centered. It should bridge the gap between the social and the medical, and should look to what can be, rather than what is. 2. Efficient communication and feedback systems should be implemented to facilitate communication between patients, health care professionals, within and between health care settings. 3. Patients and health care professionals should be empowered to identify breakdowns within the health care system, and enabled to work towards solutions.
The ideal process map
Improving part of the system Process: Chronic disease management Aim statement: Within 8 months, the dialysis clinic will liaise with local home care services to develop and trial a case management model of chronic disease management. The results for dialysis patients will include: Patients will have consistency in care, and an advocate to help navigate the health care system. Improve the transition between the community and hospital. Increase patient satisfaction with dialysis clinic by 30%. Decrease the number of adverse events by 50%. Improve functional health and quality of life by providing access to health care professionals such as a dietician, social worker or occupational therapist.
Improving part of the system Process: Communication Aim statement: Southwest Medical will develop and implement an electronic medical record (EMR) that is interoperable with those of other facilities in the community. Southwest medical will raise funds to enable completion within 18 months. The results of the initiative will include: Clinicians and patients will have access to all patient records; patients will not have to repeat their histories to each health care professional, thereby increasing patient satisfaction by at least 25%. Checks and balances will be implemented to increase quality of care. Instant flags will herald discrepancies, education needs, and contraindications for any medication prescription or treatment.
Improving part of the system Process: Discharge planning Aim statement: Within 6 months, the general medicine unit will implement a discharge and education checklist. The results for patients will include: Decrease missed referrals by 50%. Increase patient satisfaction with education, resources and clinician explanation by 45%. Improve quality and comprehensiveness of patient discharge process by 30%.
How would you know the changes made Measures a difference? Outcome measures for discharge planning: Missed nutrition assessments over 3 months. Process measures for communication: Number of times patients have to repeat health information per visit. Balancing measures for chronic disease management: Level of delays in interprofessional referrals on other units (make sure they are not increasing).
What changes will you make? Area of concern: Discharge planning procedures Change concept: Focus on error proofing Example: Patients often leave hospital without seeing appropriate health care professionals, or without education about new medications or treatment plans. Proposed change: After researching the use of checklists on similar units in comparable facilities, use, with permission, a prepared checklist, or develop one specific to the unit. Incorporate patient satisfaction with care and discharge process as a question on the checklist, or as a separate anonymous survey.
Plan your tests Questions to answer with this test: Does the use of a discharge checklist reduce the number of missed referrals on the medicine unit? Prediction: Yes How many re-admissions are prevented through use of the checklist? Prediction: 25% of re-admissions can be prevented Changes to be tested: How is the checklist introduced to staff? How is staff educated about use of the checklist? Staff compliance with incorporation of a checklist into usual care. How will changes be tested? Record number of checklists used on the unit over a three month period. Record number of patient readmissions to hospital over a three month period. Record patient satisfaction with process.
Plan your tests Who will run the test? The medicine unit; specifically the hospital research board, clinical manager, nurse educator, and unit staff. Where and when will the test take place? The test will take place on the medicine unit, during the day shift. What information is important to collect? Quantitative: How many checklists are used? Qualitative: How do patients and staff feel about the checklist? Why is it important? It is important to collect information on use and satisfaction because it directly relates to uptake and sustainability of the checklist. Who will collect the data? The data will be collected by unit staff.
Plan your tests Who will analyze the data prior to study? Research staff from the hospital will liaise with clinical manager and staff prior to the study. Patient surveys will also be reviewed. Where will the data be kept? The data will be kept in a locked file cabinet on the medicine unit. When will the collection of data take place? The collection of data will commence in the month of April 2011. How will the data (measures or observations) be collected? The data will be collected using a spreadsheet program. The clinical manager will assign two people in charge of inputting data.
What challenges might leadership face? Funding limitations Budgetary concerns may limit hospital involvement in new initiatives. This challenge can be overcome through data detailing financial benefits of checklists. Staff Engagement Staff engagement rates may be down, thereby decreasing motivation to trial new procedures. This challenge can be overcome through contests and prizes designed to engage staff, and lead to better outcomes for patients. Legislation Employment and privacy legislation may limit generalization of the checklist to all services. This challenge can be overcome through research and modification of the checklists as required.
Thank you! Quality is not an act, it is a habit. Aristotle