Patients and Professionals Partner to Redesign Inpatient Care Mireille Brosseau Program Lead, Patient and Citizen Engagement Canadian Foundation for Healthcare Improvement (CFHI) Mario DiCarlo Patient Advisor McGill University Health Centre (MUHC) Patricia O Connor Director of Nursing & Chief Nursing Officer, MUHC Marjolaine Frenette Nurse Clinician, Montreal Neurological Hospital, MUHC @CFHI_FCASS
Agenda Introduction (Mireille) Personal story (Mario) Reflection (Participants) Setting the stage (Patty) TCAB/PEP journey (Marjolaine & Mario) Reflection (Participants) Organizational impacts (Patty) Spreading change (Mireille) Call to action (Participants) 2
Tambuyzer, Pieters and Van Audenhove (2011) Patient involvement in mental health care: one size does not fit all, Health Expectations 4
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Patient Engagement Continuum 6 Anu MacIntosh-Murray, PEP Qualitative Analysis, 2010-2013
Mario s story 7
McGill University Health Centre: Co-designing Inpatient Care with Patients 8
The MUHC (2013) Montreal Children s Hospital (1912) Royal Victoria Hospital (1893) Montreal General Hospital (1955) Montreal Neurological Hospital (1934) Lachine Hospital & Camille-Lefebvre Pavilion (1913) Montreal Chest Institute (1931 & 1956) 9
MUHC Redevelopment: March 2015 The Glen Campus (RVH, MCI, MCH): Summer 2015 Mtl Neurological Montreal General Lachine
Transforming Care at the Bedside (TCAB) Developed in 2003 by the Institute for Healthcare Improvement (IHI), funded by Robert Wood Johnson Foundation to revitalize care on medical & surgical units and places care improvements in hands of the frontline staff 5 Pillars of TCAB Transformational Leadership Competencies Value-Added Care Processes Safe & Reliable Care Patient & Family Centered Care Teamwork & Vitality 11
Project Objectives Objective # 1 Objective # 2 Objective # 3 Understand the inpatient experience through the eyes of patients & families Deeply engage patients & families, along with staff, in reshaping care processes that respond to their real needs, thus improving: safety, access & work environment. Increase RN time in direct care
Implementation Plan (2010-13) Wave 1: 5 units (3 hospitals): Internal Medicine General Surgery Psychiatry Neurological Surgery Gynecology-Oncology Wave 2: 3 units (3 hospitals) Pediatrics Chest Hospital Neurology unit Teams consist of: 1 Nurse Manager 1 Asst. NM (CNS or NPDE) 2 Nurses 1 Patient Attendant 1 Unit Coordinator 2 Patient representatives Physicians Rehab therapists, social worker, dietician One day/wk staff & pt reps tested improvement ideas
Tools and Measurements Modules/Interventions: # 1:PDSA Act Study Plan Do # 2: 5S Sort, Set, Shine, tandardize, Sustain # 3: Pt Experience of care Whiteboards, Comfort Rounds & Therapeutic Questions # 4: Admission & Discharge process mapping Measurements: Staff: RN Time in direct & value-add care using PDAs Vitality Survey, focus groups Teamwork, recognition, turnover, OT, absenteeism Patients Patient Narratives HCAHPS Survey: Hospital Consumer Assessment of Healthcare Providers and Systems Patient Activation Measure Measure of Processes of Care
Reflection Question What do I see as the greatest challenge or obstacle that prevents me (or my colleagues) from engaging patients and/or their families? 15
TCAB/PEP Journey: The Patient and Staff Nurse Voices 16
Results
Module 1: PDSA Applying PDSA to test, measure, adjust & maintain new processes while engaging stakeholders Ex: Use of SBAR to Reduce Time of Report Pre : avg. 34 min Post : avg. 17 min * SBAR = situation, background, assessment, recommendation
Reducing Non-Value Time: Equipment Relocation Time saved in a yr = 1,100 hours or 0.7 FTE No more tests or treatments cancelled because wheelchair could not be located
New Team Admission in Mental Health: Clinical Efficiency Serial interviews (4.3 hr) replaced by team interview with patient (1 hr) Pre Post 5 4 4.23 Hours 3 2 Time Saved: 300 adm/yr x 4.23 hrs = 0.7 FTE 1 0 1 hr
Module 2: Improving the Physical Environment Using 5S: Sort, Set, Shine, Standardize, Sustain Before After Storage room where equipment was inaccessible, getting damaged and creating a hazard for staff
5S: Accessing Forms in Nursing Station Pre Post Pre: avg. 2 min. 36 sec. Post: avg. 30 sec
5S:Patient Redesign of Family Visiting Room Pre Post Pre: - Visitors room and OR prep room -Sharps containers and cancer pamphlets on walls Post: Example of nothing about me without me approach to redesign
5S-Measures: Dressing Cupboards Pre Post
5S-Measures: Dressing Cupboards Time (seconds) 350 300 250 200 150 100 50 0 Time required to gather 8 dressing equipment Before After Before: ~5mins After: 95 sec Total time saved: 237 sec. Total time saved in 1 year for 1 dressing change/shift : 86,5 sec/year = 24H per year
Reflection Questions What is the role of the patient in Module 1 and 2? How can we, as a team, engage our patients in redesigning our working physical space? 26
Module 3: Patient Experience of Care Implementing bundled interventions to improve patient experience of care, including use of whiteboards, comfort rounds and therapeutic questions Ex: whiteboard with basic and complex information, including: date, names of care team and phone number diagram of upcoming surgical procedure
Whiteboards:2 way Communication Tool Whiteboards adopted by patients and their families to communicate with care team and to provide support and encouragement for each other
Whiteboards & Physician Collaboration Whiteboard Audit Results
Patient Experience of Care 3 Therapeutic Questions: 1. What is your greatest concern right now? 2. What information do you need that would be the most helpful? 3. What do you need from me right now that would help you?
Patient and Family Pamphlet I wish I had received this when I first came to the floor. It would've answered all my questions!
Improving Admissions & Discharges: Inter-professional Collaboration Multidisciplinary Team Process Mapping Creating process maps to identify waste and opportunities for standardization and improvement
Process Map Ex: Discharge Swim lane Before After
Discharge Checklist: Developed by Patients for Patients While in hospital Ask your doctor for planned date of discharge. Remind healthcare team to enter planned date of discharge on whiteboard Done The date of discharge should be updated daily on the whiteboard. Communicate to the hc team your needs regarding discharge i.e.date, transport, clothes, help at home, caring for yourself after return home Ask the doctor for time off work letter, if needed. Get someone to drop off insurance papers at you doctor s office Day of discharge Make sure you have the prescriptions to prevent pain & constipation Ask about restarting medications you were taking before admission. Make sure you understand any changes in the medication you were taking before your admission (if applicable). Make sure you have follow-up appointments, if needed. Review discharge teaching sheet with the nurse.
Reflection Question What would it take in my area of work to facilitate patient engagement in our improvement processes? 35
Organization Impacts and Next Steps 36
Results: Direct Time in Care (using PDAs) 60% Time in Direct Care Results and Trend - Summary 52.2% 53.4% 51.3% 8% 50% 44.0% 43.3% 46.1% 40% % of Time 30% 20% 10% 0% 15.4% 15.7% 13.8% 13.5% 16.6% 12.7% 12.2% 13.0% 14.7% 12.9% 12.6% 10.1% 6.6% 6.5% 6.6% 5.8% 6.4% 5.7% 1.7% 1.9% 1.9% 2.0% 2.1% 4.9% Aug. 2010 Dec. 2010 July 2011 Dec. 2011 Mar. 2012 Study Dates 50% Direct Care Activities Indirect Care Activities Waste Activities Administrative Documentation 37
HCAHPS Results: Responsiveness Q: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Q: How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? (never, sometimes, usually, always) % of patients selecting top score 120 100 80 60 40 20 Responsiveness (n=287) 20% improvement 0 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 Financial Periods US Benchmark Aggregate 5 units Agg excl. Psych
HCAHPS: Medication Communication Q. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q. Before giving you any new medicine, how often did hospital staff describe side effects in a way you could understand? Medication Communication (n=245) % of patients selecting top score 100 80 60 40 20 0 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 Financial Periods US Benchmark Aggregate 5 Units Agg excl Psych 10% improvement
Other Co-design Outcomes Quiet Zone led to a 50% reduction in interruptions and 60% reduction in medication transcription errors Redesigned chemo tx room time to start chemo by 57% Voluntary Turnover: 12.6% down to 4.6% Overtime rate: 3.6% to 3.0 % (p=0.01) Alignment, relationships with union AHRQ collaboration Spread: 8 more units (Max Bell Foundation; 2013-16) 40
Successful Partnerships in Co-Designing Care Thank you for giving us this project. We are discovering our strengths and we are working together. Who would have thought this would be possible? (Co-President, MUHC Patients Committee)
Elements of Success Extensive stakeholder engagement Protected release time & facilitator support critical Having clear deliverables for each module & provide Coaching on how to conduct simple measurements that are meaningful to frontline staff Change takes time & effort. Senior leader presence was important to teams for feedback & encouragement (Executive Rounds very useful) Communicating the achievements at all levels
Lessons Learned: Patients 5S module was a turning point for engaging patients as they could provide input into what we see and how it makes them feel Patient perspectives are often different. Co-designing processes together led to respect, better ideas, new partnerships. Many patients want to be engaged in their health care treatment plans TCAB has been a wonderful opportunity to not only engage the patient, but partner with them as well
Lessons learned: Teams Building capacity at frontline & with patients outcomes New leadership & work re-organization competencies In quality improvement & measurement, Protected release time for staff & facilitator support were critical TCAB strategies create a healthier, safer, more efficient and better work environment TCAB teaches clinicians to implement change as a team and accelerates implementation of changes because the manager is not the only one making them The positive results foster buy-in from other members of the care team which is key to sustainability
Thanks to Generous Donors & Supporters Canadian Foundation for Healthcare Improvement Max Bell Foundation Canadian Institutes for Health Research Newton Foundation, Mtl General Hospital Foundation Roasters Foundation, RVH Foundation MUHC: Executive, Many leaders, Patient Committees
Summary of PEP results Three types of outcomes are emerging: Improvements to engagement itself Improvements to the patient experience (via multiple dimensions of quality) Organizational impacts (changes in culture and practice)
Spreading change
Call to action What will I do on Thursday to move Rhetoric to Action towards achieving person- and family-centred care? 48