Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management

Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management Michelle Cline, RN, MSN, Care Model Redesign Manager Donna Litwinski, PT, Master Lean Fellow April 2018

Objectives Operationalize Care Model Redesign with a supporting Lean Management System Illustrate consistent job performance in daily processes that support patient experience, safety and progression Demonstrate how to make results more transparent and actionable to improve patient outcomes

3 Static Map

MemorialCare Long Beach Medical Center LBM (Long Beach Memorial) 453 Beds 20,560 Admissions 108,000 ED visits 17,000 surgeries MCWHLB (Miller Children s & Women s Hospital Long Beach) 357 Beds 15,449 Admissions 6,000 Deliveries 8,000 Pediatric Admissions 84,000 OP visits Our Patient Population Adult 60% Medicare Adult 27% Medicare-Medi-Cal Peds: 70% Medi-Cal patients 296 Homeless Adult patients (average daily census of 9)

LIVES TOUCHED = 100,000+ Patients Area Involvement/participation 5 th Floor (Med/Surg/Resp) Pediatrics (Miller West and CORE) Intensive Cardiac Care Cardiac Monitor Unit 4 th Floor (Neuro, Ortho, Wound Care) 6 th Floor (Oncology, Surgical) Mother Baby Perinatal Specialty Care Labor and Delivery Intensive Care Cardiac Care Inpatient Rehab Facility Emergency Department Employees Involvement /participation 1400+ Registered Nurses 90+ Patient Care Associates 680+ Interprofessional 100+ leaders

Linkage to Strategic Plan & True North 6

Outcomes Where we started..2015 2 star Medicare rated hospital Magnet Deterioration * 8 out 9 domains were red # of Hospital Acquired Occurrences * 481 Falls (with, without injury) * 261 (CLABSI, CAUTI, HAPI, C-Diff) Adults: ALOS 5.6 days (Medicare) Pediatric: ALOS 4.2 days Where we are today 2018 4 star Medicare rated hospital Magnet Re-designation *7 out of 9 domains are green # of Hospital Acquired Occurrences * 400 Falls (with, without injury) * 172 (CLABSI, CAUTI, HAPI, C-Diff) Adults: ALOS 5.0 days (Medicare) Adult Discharged to Home meets GMLOS Pediatric: ALOS 3.9 days

3 Big Initiatives Care Model Redesign MemorialCare Hour Lean Management System

What is Care Model Redesign? Redesigning our care model to ensure quality patient care coordinated care (patient/family/care team) financial resilience

Care Model Redesign Objectives Communication 1. Enhance communication among the key interprofessional team members 2. Facilitate the proactive coordination 3. Identify progress 4. Identify and address barriers 5. Enable and empower the care team 6. Improve communication with patient and family Coordination 1. Perform a comprehensive patient history assessments IPA (Interdisciplinary Patient Assessment) 2. Communicate needs across settings 3. Collaborate with team members 4. Participate in care planning w/patients & family-every shift 5. Plan for smooth discharge Lamb, 2014, p. 85

Care Model Redesign Process Steps 1. Selected critical care providers and defined the work that led to improved experience, safety, progression RN Coordinator of Care 2. Selected critical processes that impact Patient Experience, Patient Safety, Patient Progression 3. Developed and documented standard work in selected critical processes that captured best practices 4. Trained front line nursing staff

Identified Communication Opportunities 1. Patient/family What s important to the patient Making it visible 2. Nurses Hand off with emphasis on patient s goals 3. Interprofessional team Involvement in patient progression 4. Leadership Physician Advisors Clinical Lead Management

RN Coordinator of Care Registered Nurses are the hub of the patient experience & coordinate patient care throughout the care continuum.

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Strategies for Care Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

Setting Goals: Interdisciplinary Patient Assessment (IPA) Who: All team members What: Asks the patient-what s important to you? What matters to you? Where: Discussion at bedside When: On admission intake of IPA in first 24 hours How: In Electronic Medical Record (EMR)

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Strategies for Care Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

Patient Communication Board : Team Goals and Recommendations-Patient Centered Who: All team members involved with the patient What: Develops patient friendly goals to work on next Where: In the Electronic Medical Records under Plan of Care for one stop shop When: Daily and/or as the plan changes How: RN on nights reviews medical plan and IP recommendations Patient decides what goals to achieve that day Write it on the board

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Works on Strategies Care for Care Proression Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

Hand Off Communication: Professional Exchange Report Who: On-coming RN & off-going RN What: Discusses agreed goals, any barriers to accomplishing the plan, & what matters to the patient Where: Discussion at bedside When: Change of shift: AM and PM How: On-coming RN & off-going RN manages up/introduces one another while assessing; and discussing with patient the plan for the day

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Strategies for Care Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

Patient Progression Huddle Care Briefing by Clinical Leader What is a Clinical Leader? Facilitates daily Care Briefings Coaches staff with progression of care Collaborates with Interprofessional leaders Identifies opportunities for improvement Who: Bedside RN (coordinator of care & also voice of the patient) and Interprofessional team members What: Discusses agreed goals, any barriers to accomplishing the plan, & what matters to the patient Where: In hallway of unit When: Monday thru Friday scheduled time (in the morning) How: Clinical Leader facilitates group 22

Benefits to InterProfessional Teams Addressed patient and family concerns Electronic Form to Document Key Discussion Points Care Coordination is a 24/7 process Established Quality Review Process

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Strategies for Care Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

Escalations Rounds with Leadership Involvement Who: Unit Clinical Leads, Nursing leadership, MD Advisors, IP leadership What: Discusses any barriers that will need leadership intervention Where: Same location Monday thru Friday When: 1300 How: Determine plan to resolve

Care Model Redesign Escalation Rounds to remove barriers to Patient progression Interprofessional Team Care Briefings to discuss Patient progression Interdisciplinary Patient Assessment: electronic communication Implement Strategies for Care Progression Professional Exchange Report (PER) & review of goals with Patient Team Goals & Recs on Patient communication board

CMR 2.0: Identified an opportunity inclusion of other Interprofessional (IP) team members Revisited current CMR (nursing focused) Adopted/adapted standard work for the roles of 6 critical departments (Care briefings participants) Designed standard work for handoff, care briefings, workflow Biggest win: Entering and exiting a room standard work

Campus wide Standard Work Entering and Exiting a Room

Reliable methods/job aides

Established daily routines

3 Big Initiatives Care Model Redesign MemorialCare Hour Lean Management System

What is MemorialCare Hour? Who: Nurse Leaders Interprofessional Leaders What: Touch point by leaders with each patient/family Where: At patient bedside When: 2-3 pm Why: #1 Impact patient experience #2 Ensure sustainment of standard work #3 Address any gaps and develop a plan

Impacting the Patient Experience with MemorialCare Hour

3 Big Initiatives Care Model Redesign MemorialCare Hour Lean Management System

What is a Lean Management System? A system that guides and directs the actions and efforts of the team that promotes personal and organizational success The goals of a Lean Management System is to *Develop People *Solve Problems *Improve Performance

Identified Operational Drivers Patient Experience Achieve a 5 star rating from CMS Achieve top box scores for patient experience in all categories Response, Courtesy & Respect, Pain Management, Education Patient Safety Prevent Hospital Acquired Conditions (HAC) Falls, CAUTI, CLABSI, VTE, and HAPI, etc. Maximize pay for performance incentives Patient Progression Reach LOS annual goal

ESP: Experience Safety Progression ESP is very descriptive of someone (or a group) knowing what is going to happen and when it is going to happen Use Lean methods, mindset, and management system to predict/affect the results and outcomes that specific actions will produce.

Ideal Behaviors = Ideal Results Leader (ALIGN) Manager (ENABLE) Staff (IMPROVE) Routinely set and share vision Model/coach management Know if/where we re winning or losing today Identify opportunities to share/spread learning Own unit level goals and outcomes Communicate purpose & meaning of systems Model/coach staff to discover root cause, find countermeasures, and improve processes Respond to real time data Acknowledge problems for permanent problem resolution Own and operationalize patient plan of care to provide an excellent patient experience Use and improve the tools Measure and monitor process performance Identify problems/issues and offer potential solutions Adhere to operational standard work Leader/Manager (shared) Adhere to leader standard work Regularly go to gemba to identify & remove barriers Recognize and celebrate Use and improve the management system Manager/Staff (shared) Remove barriers (patient care) Recognize and celebrate

Roadmap CMR LMS 1.0 IP CMR LMS 2.0 Design Test & Adjust Operate Design Test & Adjust Operate Design Test & Adjust Operate Design Test & Adjust Operate 12 PATIENT CARE UNITS, EMERGENCY and 9 INTEPROFESSIONAL DEPARTMENTS

Cascading Goals and Metric Campus CNO VAT Nursing Division Service Line Dept. Unit The Pursuit of Perfect Care Link to Strategic Plan Cascading Goals and Metrics

ESP Targets HCAHPS: 75 th percentile top box Medicare ALOS: 4.5 days (Adult) Medi-Cal ALOS: 6.0 days (Adult) 5.0 days (MCH) 3.0 days (Women s) HACs: Zero occurrences

How to start? 1. Identify Key Performance Indicators 2. Review and analyze your results 3. Determine the gap 4. Perform Root Cause Analysis to identify what processes impact results 5. Select critical processes Measure daily Make it visible Huddle daily 6. Determine the plan to address the gap in reaching target (plan for today and ideas for tomorrow)

Operational Drivers.Reviewed Current Results Patient Experience Press Ganey Scores Patient Safety Hospital Acquired Conditions Patient Progression Lead Time, ALOS

Control Board (Tier 1)

Department Board (Tier 2) Result Metrics Process Metrics Roll-up

Tracking HACs

Service Line Board (Tier 3) Nursing Division Board (Tier 4) Tier 3 Tier 4

48 Let s Practice PROCESS VS. RESULT METRICS

Process versus Result Metric Discharge within 2 hours after order is written

Process versus Result Metric Patient Complaints

Process versus Result Metric # of Unusual Occurrence Reports

Process versus Result Metric Response Time to Call Button

Process versus Result Metric Patient Satisfaction Surveys

Process versus Result Metric Bed Alarm is on for high fall risk patients

JUNE Continuous Improvement Process to calculate # of ideas submitted/ # of ideas implemented throughout the areas IDEAS SUBMITTED IDEAS IDEAS IMPLEMENTED JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH AT WORK, MY OPINION ALWAYS COUNTS!!! APRIL MAY

Then what????.leader Standard Work discipline How do you know how your area is doing? MemorialCare Hour Control Board Huddles Standard work audits

Leader Standard Work: Control Board Huddles

Leader Standard Work Kamishibai Boards Step 1: Pull a card Step 2: Observe all steps, assess and coach Step 3: Document and display the results PDSA

Leader Standard Work (Leader s Routine) Tier 1- AUM Activity Frequency (minimum) Purpose DAY AUM to AUM/RC hand off Daily To share information (as per standard work) to oncoming AUM/RC to ensure a safe and effective hand off Care Briefings Daily To cover staff RN for immediate patient need otherwise observe the process to determine how the unit is operating and provide resources as needed Leaders are held accountable in performing their standard work MemorialCare Hour Control Board Huddle Daily Daily Perform assigned zone patient interviews and address any concerns, perform standard work observations, complete audit form and place results on control board as appropriate; engage with staff/families Lead huddle (RC to lead when there is no AUM coverage) adhering to standardized agenda Continuous Improvement Weekly Triage ideas, assess, assign, account Just Do Its Standard Work Audits Daily To observe the entire process, evaluate adherence, give feedback/coach NIGHT AUM to AUM/RC hand off Daily To share information (as per standard work) to oncoming AUM/RC to ensure a safe and effective hand off MemorialCare Hour (night version) Control Board Huddle Daily Daily Perform patient interviews and address any concerns, perform standard work observations, complete audit form and place results on control board as appropriate Lead huddle (RC to lead when there is no AUM coverage) adhering to standardized agenda Standard Work Audits Daily To observe the entire process, evaluate adherence, give feedback/coach Maintain visual management Update control board graphs with system new graph and place weekly Weekly (Sunday) average on Tier 2 board

Transformation: Culture Change I feel I am not fully doing my job if I am not checking for a fall risk band and to see if the bed alarm is on when I visit a patient. Shanshan Song Registered Dietician

Transformation: Culture Change When I went to Diane (director) with a problem she would just fix it. Now she coaches me how to solve the problem. Penne Baray, RN, Assistant Unit Manager Birth Care Center

Transformation: Culture Change Leader Standard Work has shown me that it is better to flame the embers of ideas and solutions of the front line staff than to try to be a firefighter. Mary Margaret Montgomery, PT Director of Rehab Services

Transformation: Culture Change Involving your team empowers all of us together to improve clinically, professionally and personally..all that benefits the patients and families. Kim West, RN Director of Clinical Operations ICU/CCU

Top 10 Ah Ha s #10 Don t limit the ability to standardize with we are different #9 Starting small is essential to going big #8 Be sure to include the entire Interprofessional team #7 Don t depend on local heroes; make it a team effort #6 Don t expect this to be perfect; be patient with the process #5 Leadership must drive the efforts and role model the behavior #4 This takes discipline #3 Just because standard work is created, doesn t mean it is being followed #2 Everyone must know the Why and What s In It for Me #1 Staff must understand the value in everything they do and how it impacts patient care it is essential to always keep the patient/family in the center

Next steps Continue spread CMR/LMS Upcoming LMS (Perioperative Services, Miller Children s Out-Patient Specialty Care) MemorialCare Experience (Simply Better)

Simply Better

Questions: The Faces Behind the Work

Thank you Mcline@memorialcare.org Dlitwinski@memorialcare.org