Quality Improvement Project Report Out Queens Home Care RN Making Time to Care
Define Increasing capacity in Home Care nursing (Queens) with a focus on documentation
Define Problem Statement Our current nursing documentation process is repetitive and time consuming which negatively impacts on staff, client/family and the organization as a whole. Documentation is often duplicated, fragmented and inefficient due to the physical environment, lack of computer skills and lack of standardized charting guidelines.
RN Team Leader Preparing New Results Client Chart 42 new client charts created over 3 week period Average time to prepare chart 44 minutes Average number of interruptions per chart 5.6 Average number of interruptions per chart on Fridays 7.5
RN Team Leader - Interruptions 10 9 Average # of Interruptions at Different Times of Day 8.75 8 7 6 6.25 5 4 4.07 4.75 3.67 3 2 1 0 8:00-9:59 10:00-11:59 13:00-14:59 15:00-16:00 after hours
RN Preparing New Client Chart Results 16 new client charts prepared over 3 week period Average time to prepare chart 14 minutes Average number of interruptions per chart 2.2 Phone Calls Distractions /Noise 37% 20% Staff Coming Into Office 43%
RN Preparing New Client Chart Impact of Interruptions Charts completed with 0 interruptions 4 Average time to prepare chart with no interruptions 8 minutes Duration of Interruptions Average time lost to interruptions per chart 8.1 minutes Total estimated time lost to interruptions over 3 week period 2.2 hours
Occurences Documents/Assessments Completed in the Home 25 20 15 10 5 120% 100% 80% 60% 40% 20% - Nursing Notes Med Service Rec/Med Agreement Care Plan CDS Schedule TLR Falls Physical Assess Profile All other 0% Quantity 22 20 18 18 14 13 6 6 4 0 Cum % 18% 34% 49% 63% 75% 85% 90% 95% 98% 100% % of Total 18% 16% 15% 15% 11% 11% 5% 5% 3% 2% 0% 0% 0%
Documents/Assessments Completed in the Home Total time per client 36 minutes Min 10 minutes Max 1 hour 45 minutes Average Time to Complete by Type of Document/Assessment (minutes) 0:17 0:14 0:15 0:14 0:11 0:08 0:05 0:10 0:10 0:08 0:07 0:07 0:05 0:02 0:00 0:00 Physical Assess Med Rec Invasive Procedure Other Falls CDS TLR Service Agreement SAST
Occurences Documents/Assessments Completed in the Office 25 20 15 10 5 120% 100% 80% 60% 40% 20% - Nursing Notes Med Rec/Med Profile Service Agreemen t Care Plan CDS Schedule TLR Falls Physical Assess Invasive Procedure SAST Other All other 0% Quantity 22 20 18 18 14 13 6 6 4 2 - - 0 Cum % 18% 34% 49% 63% 75% 85% 90% 95% 98% 100% 100% 100% 100% % of Total 18% 16% 15% 15% 11% 11% 5% 5% 3% 2% 0% 0% 0%
Documents/Assessments Completed in the Office 0:43 0:36 0:39 Average Time to Complete by Type of Document/Assessment (minutes) 0:28 0:21 0:18 0:14 0:07 0:10 0:09 0:07 0:07 0:06 0:06 0:05 0:05 0:00 0:00 0:00
Documents/Assessments Completed in the Office Total time spent per client, completing documents/assessments in the office Min 30 minutes Average 1 hour, 20 minutes Max 2 hours, 8 minutes Total time spent over 3 week period 29 hours, 27 minutes
Documents/Assessments Interruptions Completed in the Office 164 total interruptions for 23 charts Average number of interruptions per chart 7.5 Phone Calls 11% Other 14% Distractions/ Noise 30% Staff Coming Into Office 45%
Documents/Assessments Completed in Impact of interruptions the Office Average time lost to interruptions per document/assessment 2.6 minutes Average total time lost to interruptions per chart 31.6 minutes Total time lost to interruptions over 3 week period 11.6 hours Charting 61% Interruption 39%
Analyze Key Points Impact of Interruptions (per chart-31.6 minutes) Average time lost to interruptions per chart 8.1 minutes RN team leader- Average time to prepare chart 44 minutes with 5.6 interruptions per chart (bulk of those between 1PM and 4PM) Staff coming into office and distraction/noise significant issues! Documentation in office = Average 1 hour, 20 minutes Total time per client in the home 36 minutes (CDS= 7mins)
Improve Aim statement: Through the development of PDSA s we will decrease the amount of time spent on documentation with new admissions by 36% by Jan. 13/14 via the elimination of the Common Data Sheet, decreasing interruptions and standardizing chart preparation.
Improve PDSA 1 Remove Common Data Sheet Common data sheet will be eliminated from all new admission charts starting Dec. 2/13. Intake and Liaisons will start entering in the directions to the client s home under client profile when required. Actions Make liaisons and intake coordinator aware to enter the directions under the client profile on ISM Remove all paper copies of the common data sheet from the office and new central files Educate care coordinators of the change at CCR Educate RN s on the removal of common data sheet Educate Admin staff re: audits
Improve PDSA 2 Reduce interruptions Decrease the number of interruptions by using stop and meeting in progress signs in the common area and office doors and also using stop-documentation in progress signs for each individual desk. Actions Make signs Educate all staff on the use of the signs Create a one pager on the baseline data collected and what that means for staff Educate Care Coordinators on the use of the signs at CCR
Improve PDSA 3 Training on work items in ISM To decrease interruptions staff nurses will be trained to send work items forcommunication purposeson clients and duplicate RN team leader on each of the work items. Staff will also receive refresher training on ISM components to decrease the amount of interruptions to other staff re: ISM related questions. Actions All nurses will be trained on work items Refresher training for part time staff on ISM Check with part time staff to see who requires additional training (beyond work items) Inform staff about being self sufficient revolving around the use of ISM to decrease interruptions
Improve PDSA 4 Streamline Team Leader process for new charts Process to create paper chart for new admissions will be re-evaluated and reviewed. Actions Review and revise current process to identify potential efficiencies Changes relating to the revised process will be noted and carried out as Actions once they are identified by the review process Team Leader will introduce huddles in January to update all staff nurses and schedule individual meetings to provide each nurse with charts for their new admissions for that day.
Improve RN team leader preparing new client charts (time to complete, interruptions) = 16 clients (42 baseline measurements) RN preparing new clients chart (time to complete, interruptions) = 7 clients (16 baseline measurements) RN completing documentation back at the office (time to complete, interruptions) = 11 clients (23 baseline measurements)
Improve RN team leader s time to prepare chart decreased from 44 minutes to 21 minutes and number of interruptions per chart decreased from 5.6 to 1.3 50 45 40 35 30 25 20 15 10 5 0 Time to Prepare Chart # Interruptions Baseline Post Interventions
Improve RN Preparing New Client Chart - Interruptions Baseline After Interventions Distractions /Noise 37% Phone Calls 20% Distrat ions/ Noise 38% Phone Calls 18% Staff Coming Into Office 43% Staff Coming Into Office 44%
Improve RN Preparing New Client Chart Increase time to prepare new chart from 14 min to 20 Increase interruptions per chart from 2.2 to 5.1
Other 14% Improve Documentation in Office Phone Calls 11% Other 4% Phone Calls 15% Distractions/ Noise 30% Staff Coming Into Office 45% Distractions/ Noise 43% Staff Coming Into Office 38% Baseline After Interventions
0:43 0:36 0:39 Average Time to Complete by Type of Document/Assessment (minutes) Baseline 0:28 0:21 0:18 0:14 0:07 0:00 0:10 0:09 0:07 0:07 0:06 0:06 0:05 0:05 0:00 0:00 0:36 0:28 0:32 0:21 0:14 0:07 0:13 0:15 0:06 0:09 0:05 0:05 0:06 0:05 0:00 0:00 0:00 0:00
Documentation Changes to document each assessment: Med Rec - decrease 7 min Nursing notes - decrease 5 min Physical assessment- increased 5 mins Service agreement - decrease 3 min Care plan increased 2 mins Invasive Procedure- decreased 2 mins Falls - decrease 1 min TLR no change CDS- saved 5 min Schedule no change
Improve Team leader s time to prepare chart decreased from 44 minutes to 21 minutes (52% improvement) Team leaders # of interruptions per chart decreased from 5.6 to 1.3 (77% improvement) RN preparing chart time increased time from 14 min to 20 min Increase interruptions per chart from 2.2 to 5.1 RN finishing documentation in office decreased from 1hr 20min to 1hr 3min (21% improvement) Interruptions back at the office increased per chart from 7.5 to 8.5 Chart audit results: 96% compliance with removal of CDS
Improve Staff comments and customer feedback on the improvements
Controls Intent of good control is to maintain the desired way of completing a task and ultimately the most efficient way to achieve the customer s needs Validating the controls in place, from the PDSA s are appropriate/functioning Deciding factor of which controls to use should be based on the risk associated with slippage
Types of Controls 10. Written Signs 9. Polices and Procedures 8. Checklist 7. Audits 6. Continue to Measure 5. Training 4. Standard Work 3. Visual Controls 2. Error Proofing 1. Fundamental Change
Control What controls have we put in place to ensure that performance does not lapse? Training on work items Procedure include work items in ISM training for new nurses Standard work using work items for communication Fundamental change eliminating CDS Audit CDS audit (Admin); audit use of work items (Team Leader) [1, 3 and 6 months] Re-measure time spent by Team Leader preparing chart [1,3 and 6 months]
Spread Plan How will we share the results of our project? Share report out project with Director, CCR and Queens staff Darlene to share experience with work items at Nursing Team Leaders meeting Share with Health PEI at Lean celebration day Feb 27th
Lessons Learned What were some of the key things we learned about quality improvement while doing this project? Limitations of the physical environment Opportunity for more communication to staff (increase awareness of the project) It is possible to reduce your workload with small changes Change is hard and pulls you out of your comfort zone
Next Steps What next QI project or where is the project spreading? Trial huddles (weekly) Trial moving CCR meeting to HH classroom Re-circulate info sheet to staff Consider re-organization of nursing supplies as next Lean project
The Team! Jeanne MacDougall, Marilyn Walker, Nancy McDonald, Marilee Miller, Suzanne Matthews, Darlene Lawless, Mary Roberts, Elaine Betts and Shelley MacCallum