Case Study Competition 2010: Communicating with Carla IHI Open School- October 14, 2010 Seattle, WA Chapter
Introduction Team Members: IHI Open School-UW Chapter Case Competition 2010 1) Betty Harrill (UW School of Nursing, Master's Student) 2) Erin Abu-Rish (UW School of Nursing, PhD Student) 3) Jessica Mosely (UW School of Medicine, Medical Student) 4) Joanna Preker (UW School of Pharmacy, PharmD Student) 5) Lapio Choe (UW, Undergraduate Pre-nursing Student) 6) Tracy Yep (UW School of Pharmacy, PharmD Student)
Overall Process Map Day 1: Home Work Part-Time Dialysis 3x/week Referred for Ultrasound (late, not completed on Day 2 as scheduled) Day 3: Dialysis Referred to ER (low flow, high K+), admitted to Hospital (tpa, heparin, warfarin) Day 7: Hospital Discharge/ Teaching, INR f/u scheduled w/pcp then Dialysis after SW coord. Day 7 cont.: Nutrition consult ordered, Pt tired, leaves D/C instructions in car, phone d/c d Day 25: ED visit (arm pain, new DVT, low INR), Warfarin not monitored at Dialysis as ordered Admit to Hospital x 10 days (to achieve INR), arm pain=narcotics, some communication btwn hospital and dialysis, nutrition consult/handouts Day 36-38 Lonely Birthday in Hospital, feeling ill at home (skips dialysis), face tingling not feeling well. Day 39: ER for face tingling, cursory neuro exam, high K+, tx d to dialysis then to floor, high INR not noted and continued tingling not explored Day 40: Med student notes tired, during rounds attending orders CT due to high INR, Dx d with subdural hematoma ICU, surgery, FFP, slow recovery Hematoma removed, bleeding stopped, Tx d to long term care facility that can meet dialysis needs. Health Care Players: 1) Carla, 2) PCP clinic, 3) Dialysis Clinic, 4) Hospital/SW, 5) Long-Term Care Facility
Contributing Factors? Mercedes made ultrasound appointment without finding a time that worked for Carla. The hospital would not perform ultrasound because Carla was late. Carla was discharged on a Sunday with no counseling from a nutritionist and very little information about proper dietary restrictions when taking warfarin. There was no confirmation with Carla regarding her appointment with the nutritionist. Carla s INR was not monitored at the dialysis clinic. When Carla was admitted due to facial tingling, her critical INR value was not identified as a problem until the next day. The ED physician likely only performed a cursory neurologic exam and potentially missed signs of an acute subdural hematoma. Bottom line: Patient handoffs were inadequate Patient education was not completed Care coordination was not available or sufficient Inferior or inconsistent technology
Create Rules for the System Stay in communication with the patient Attempt ways of reaching the patient beyond traditional methods of correspondence mail and phone calls. Persist when communication becomes difficult. Keeping in contact with Carla would have brought to light some of the issues apparent in her treatment earlier (e.g., high potassium, scheduling and transportation trouble) Communicating with Carla through multiple forms of contact would have avoided potential oversight on part of health practitioners when traditional methods failed (e.g., when Carla can t be reached by phone, a visitor may still be able to check up on her at home). Having this simple rule in mind emphasizes the importance of communication through all levels of a complex healthcare system and improves care by tracking patient handoffs.
The Ideal Process Map PCP Hospital Dialysis Clinic Care Coordinator ER The new Care Coordination program will reduce miscommunications and errors by centralizing communication between public and private facilities and patients. These changes will increase patient satisfaction and safety. Carla
Improving Part of the System Patient Education/Handouts The aim is to have cohesive and complete information prepared by professionals available upon discharge for each patient that can be used as an education and reference tool once they are at home. Patient Handoffs The aim is to standardize handoffs within a year for all patients entering or exiting the facilities. In addition to handoffs, sufficient follow up procedures should be created and implemented. Staff Education The aim is to increase the quality of patient care through better understanding of disease states and treatment barriers and give staff tools for use in the workplace. This can be achieved through required seminars for staff provided on a monthly basis or workshops.
How would you know the changes Process: made a difference? 1) Survey of patients (targeted satisfaction before and after implementation); 2) ER visits/referrals r/t dialysis complications; 3) Staff achievement of learning objectives (e.g. handoffs, delivery of patient education, etc.). Outcome: 1) Increased patient satisfaction and knowledge of care resources; 2) Increased quality of patient handouts; 3) Increased teaching/documentation of handouts being given to patients; 4) Reduced dialysis complications. Balancing: 1) Cost comparison of staff workshops and patient handouts, with ER/adverse event costs.
What changes will you make? Implement new model of patient care coordination that will be responsible for system improvements, including: Harmonizing patient handoff procedures between all facilities that promote patient advocacy; Training staff in new patient handoff procedures; Improving patient education handouts and standardizing between facilities; Rewarding and encouraging patient advocacy; Implement pilot project to assign all dialysis patients to a care coordinator (with potential roll-out to other patient care areas)
Tests: Patient Surveys in Dialysis Plan to test proposed changes: What questions do you hope to answer with this test, and what do you predict the answers are?: Hope to determine whether patient care and patient perceptions of care have improved through targeted patient satisfaction survey that will assess both general satisfaction and disease/care specific knowledge. Predict that both patient care and patient perceptions of care will have been positively impacted by changes. What changes will be tested?: 1) whether patient education/handouts have improved and are being used, 2) success of patient handoff training, 3) whether staff are implementing changes from training modules. How will the changes be tested (consider small scale early)?: Detailed patient satisfaction/knowledge survey at 0, 3, 6 months and then q 6 months ongoing.
Tests: Slide 2 of 3 Who will run the test?: Care Coordination team comprised of student assistants, representatives from clinic, dialysis, and hospital systems to be coordinated by hospital social worker and student research assistants. Where and when will the test take place?: Survey to be administered to dialysis patients during one of their thrice weekly dialysis sessions during a 2-week period at 0, 3, and 6 months and then 6 months ongoing. What information is important to collect?: 1) patient satisfaction with health care services, 2) patient comfort/knowledge of who to call with questions/ concerns. Why is it important?: Data obtained from patients will provide a snapshot of the healthcare system from the patient perspective.
Tests: Slide 3 of 3 Who will collect the data?: Student volunteers under social worker/care Coordination Team supervision/training Who will analyze the data prior to study?: Care Coordination Team to analyze previous satisfaction surveys (to provide background data prior to baseline survey administration) Where will data be kept?: Data to be kept in HIPAA compliant electronic database at medical center. When will the collection of data take place?: 0, 3, 6 months, timing tied to implementation of handoff training and patient education improvements. Data collection to continue q 6 months ongoing. How will the data (measures or observations) be collected?: Surveys to be administered by student volunteers during patient dialysis sessions.
Leadership Challenges? Obstacles to overcome? 1. General resistance to changing practice 2. Budget concerns 3. Complexity of system involving public/private players How to overcome obstacles? 1. Involve patients and staff in process and get buy-in. 2. Track budget impacts of this project (make the business case). 3. Involve student volunteers to assist with data collection, analysis, etc.
Thank you! Questions? Feel free to email the IHI Open School- UW team! ihiuw@uw.edu