IHI Open School Advanced Case Study October 14, 2010 Clemson University Catherine Simmons 1, Drew Sargent 1, and Kate Wright 1 Public Health Science Hallie Bagnal 2 and Megan Hohenberger 2 Biological Science Tyler Matt 3 General Engineering Ashley Kay Childers, PhD Research Assistant Professor Department of Industrial Engineering John Whitcomb, PhD, RN, CCRN Assistant Professor Department of Nursing 1 Seniors, 2 Sophomores, 3 Freshman
Presentation Overview Actual process map Slides 3 and 4 Summary of what went wrong Slides 5-7 New rules for improved care Slide 8 The new process map Slide 9 Potential improvement: Appointment Scheduling Slide 10 Combined IHI s suggested Slides 6 10 Potential improvement: Case Managers Slide 11-12 Combined IHI s suggested Slides 6 10 Concluding remarks Slide 13
Case Study Process Map: What Happened? Day 1 Technician notes poor blood flow during dialysis Nephrologist orders ultrasound Nurse gives handwritten appt. order Carla doesn t tell the nurse that she has no car EVENT NOTE Day 2 Carla is late for the Radiology appointment Policy is that pts 15+ mins late are Clerk automatically reschedules Carla goes home Day 3 Carla arrives for dialysis as usual Policy is that pts 15+ No mins blood late flow are through fistula Nephrologist orders blood tests Carla is sent to ED for high potassium Policy Potassium is that level pts 15+ treated mins late with are medications Ultrasound Ultrasound shows blood clot within fistula/vein Carla is admitted to the hospital Policy Dialysis is that to pts 15+ correct mins late high are potassium Temporary dialysis catheter placed in neck Carla starts on heparin and warfarin tpa breaks up Carla s clot Day 7 Nurse reviews discharge instructions Nurse Policy tells is that Carla pts 15+ to mins have late INR are checked weekly Carla tells nurse it will be difficult to check INR Nurse and social worker develop plan for INR Policy Social is worker that pts 15+ suggests mins late Carla are meet nutritionist Foods can interact with warfarin No nutritionist available on the weekend Nurse requests order for nutritionist Carla leaves discharge orders in friend s car Carla is discharged Discharge orders mailed to primary care Day 8 Hospital makes nutritionist appt for Carla Policy Appt desk is that can t pts 15+ reach minscarla late are to give appt. info Case worker mails appt. slip No way to know whether Carla receives appt info Day? Policy Carla is does that not pts 15+ mins show late for are nutritionist appt Friend brings Day 25 Carla to ED with rt. arm pain/swelling Policy Carla has is that deep pts 15+ mins venous late are thrombosis Carla s INR = 1.1 No one has been checking INR or warfarin dosage Policy is that pts Carla admitted to 15+ mins late are gen. med. unit Carla placed on heparin and warfarin Carla requires narcotics to function Social worker calls dialysis clinic about INR Carla gets written info about diet Carla s diet counteracts warfarin Carla meets with nutritionist Resident calls nephrologist about INR
Case Study Process Map: What Happened? Day 36 Carla is discharged after dialysis Carla spent 30 th birthday in hospital Visitors limited due to restrictions Carla feels nauseated and vomits EVENT NOTE Day 38 Carla feels too sick and skips dialysis Nurse is surprised Carla isn t there Nurse calls cell phone but it s disconnected Nurse considers calling police but forgets Carla s face is tingling but she doesn t go to ED Day 39 Tingling is worse, Carla goes to ED Policy is that pts 15+ Carla mins arrives late are at 1pm Carla waits 2 hrs before labs are drawn Physician s exam is non-focal, cursory exam Policy Labs show is that high pts 15+ potassicum, mins late lab are tech calls ED ED nurse contacts ED physician ED physician pages nephrology fellow Nephrology fellow sends Carla to dialysis Policy Carla is treated that pts 15+ for mins nausea late are not tingling Carla complains of face tingling and nausea Carla arrives at med. surg. unit at 6pm INR of 5.3 entered in comp. by lab tech Day 40 Med. student notices Carla seems tired Policy Student is that waits pts 15+ for mins rounds late to are voice concern At 9am, student speaks to attending Attending looks up lab results and notes INR Attending Policy is that orders pts 15+ CT mins of Carla s late are head 90-min delay for radiology results Carla has subdural hematoma Carla transferred to ICU Hematoma removed, bleeding stopped Neurosurgeons take Carla to OR Care team gives frozen plasma As a result Hospital makes of these events, Carla: nutritionist appt - has slow recovery for Carla - is left with short-term memory deficits - is no longer able to live on her own - is admitted to a long-term care facility - is the youngest resident in the long-term care facility
What Went Wrong? Patient Characteristics Carla does not have a phone; therefore, she cannot be contacted for follow-ups Day 25: Carla was sick enough that she needed narcotics to function Incomplete Care: Patient Education Day 3: Carla was not informed the risks and interactions associated with her new medications (no handouts, discussion, or teach back) Day 7: Carla needed to see a nutritionist, but the nurse and social worker did not explain why (patient should have at least been made aware that some diets can have effects) Day 7: Carla was not given the opportunity to confirm that she understood instructions and risks Day 25: Carla s diet was not being monitored Incomplete Care: Individual Staff Day 3: The nephrologist who had initially ordered the ultrasound did not follow up at Carla s next appointment two days later. In addition, he was inconsistent in his tests (ordered ultrasound on the first day, ordered lab work on the third day) Day 30: Carla s INR of 5.3 was not flagged in the lab Incomplete Care: Other Day 3: Dialysis as usual, no follow up Day 7: Carla and medical resident did not follow up regarding INR Day 26: Carla did not show up for dialysis: the clinic did not follow up with additional contacts Day 26: Carla did not understand that tingling was an indicator of a problem Day 30: Hospital addressed the nausea, not the tingling Day 30: The chart was not reviewed when Carla was put on the floor (why did no one see the lab results or history? Was history and physical updated?)
What Went Wrong? continued Unverified Assumptions Day 1: Nurse made ultrasound appointment without consulting Carla Day 1: Nurse assumed that Carla would be able to make the appointment Day 1: Poor communication regarding appointment perhaps Carla should have been warned of the hospital s late policy Day 2: Ultrasound canceled automatically without consulting the clinic Day 2: Ultrasound automatically without consulting the patient Uncoordinated Care Day 2: Radiology department was not informed about Carla s circumstances Day 7: The social worker and nurse did not coordinate care by following up with other providers Day 7: The nurse relies on Carla to ensure that her INRs are checked Day 25: No one is ultimately responsible for Carla Day 30: Carla should not have received a non-focal classification during ED visit Institutional Context Day 1: Carla was sent to a new, separate facility for the ultrasound Day 1: The dialysis clinic is not connected with the hospital There is a lack of interaction between the electronic and paper medical records as well as between the dialysis clinic and SouthWest Work Environment/Culture Day 2: Radiology receptionist is afraid of being yelled at Day 31: The medical student did not alert the attending when Carla seemed overly tired. A healthy work environment was not supported at a variety of steps in the process
What Went Wrong? continued Systems and Policies Day 2: Carla was denied an appointment throughout the entire day Day 3: Was Carla screened before tpa? Day 7: The orders were mailed to Carla s primary physician, not to Carla or the dialysis clinic Day 25: Carla was not flagged as an at risk patient because of her medications Day 26: The dialysis clinic did not follow up with emergency contacts when Carla did not show up Day 30: The triage screening process did not catch Carla she waited too long and was classified as non-focal Day 30: Physician gave cursory exam only No Patient Advocate Lack of social support Day 7: Carla was discharged alone and did not fully understand discharge instructions Other Lack of compassion perhaps Carla does not take charge of her own health because she feels that there are obstacles and rules that work in favor of the healthcare workers rather than allow them to provide patient-centered care Additional Questions Was Carla a candidate for a home health program?
New, Ideal Rules that Could Lead to Improved Care Any appointment information should be validated with the patient including date, time, and transportation. The radiology department should change the appointment rules such that any late patient will be seen as soon as possible preferably on the same business day (though they may have to wait). Any patient with multiple chronic illnesses and/or requiring regular treatment or continuous care at more than one healthcare site should be assigned a case manager. All patients (or a responsible party) must use the teach back method to communicate that they comprehend the discharge instructions and proper medication administration and risks. Any patient who does not give notification of a missed appointment should be contacted before the close of business. In the event a patient cannot be reached, an emergency contact must be informed. All lab technicians should be trained to recognize any critical lab values, regardless of whether IT systems are capable of identifying those values. All critical values should be immediately reported to the floor where the patient is located. Smart IT systems should be developed such that patient information and alerts follow the patient and are available to all care providers.
The Ideal Care Process The presence of one of more of the rules on the proceeding slide could have altered the actual circumstances dramatically. For example, a different scheduling policy in the hospital s Radiology department could have altered the entire process map: Day 2 Carla is late for the Radiology appointment Policy is that pts 15+ mins must wait Carla waits for ultrasound Carla has ultrasound Deep venous thrombosis discovered In addition, had Carla been given complete information regarding her medications and had someone been coordinating her care and following up the entire process could have changed so that Carla could be treated quickly and efficiently. If IT systems were advanced enough to incorporate decisions, compare risks, and streamline treatments, the ideal care process would change for all patients.
Improving the System: Appointment Scheduling The radiology department will change the appointment rules such that any late patient (whom) will be seen as soon as possible preferably on the same business day (by when); therefore, any patient who arrives for an appointment will be seen (how good) This could be implemented now. Because of the historically high rate of noshows, empty slots should be available for patients. Our recommendation is to implement this change now, track measures for a month, evaluate performance, and implement the policy or modify if needed. Measures to track progress: Number of cases (process measure should be reduced) Percentage of on-time (within 15 minutes) appointment starts (process measure) Revenue (outcome measure should be increased) Patient satisfaction (outcome measure should be increased) At this time, we do not see any costs associated with implementing this policy. We cannot foresee any leadership resistance unless no shows are typically used as buffers for longer appointments. More information about the current state of appointments would be needed to further address this.
Improving the System: Case Managers To ensure patients (whom) will receive safe, monitored, effective, patientcentered, efficient and timely services (how good) patients with complications from multiple, chronic diseases and patients requiring services from multiple healthcare providers will be offered services of a case manager that will help: Ensure patients are properly educated about risk associated with their treatments; Coordinate care across the continuum; Ensure patients concerns and needs are met, that the patient has social and emotional support systems, and that the patient feels the healthcare system works in their favor; Ensure expected outcomes are achieved and that patients are discharged in a timely manner; Review charts to manage resource utilization and ensure that all services were provided and none were repeated; and All of these services would have improved Carla s care, and whether one person would be able to fulfill all duties or whether multiple managers should be hired for the various steps should be determined based on the size of the facility and the financial resources available.
Improving the System: Case Managers (continued) Measures to track progress: Patient satisfaction (outcome measure should increase) Number of redundant, unnecessary tests (process/outcome measure should decrease) Readmission rates (process/outcome measure should decrease) Patient length of stay (process measure should decrease) Utilization (process measure should increase) Costs associated with implementing this strategy include the cost of hiring case managers and may lead to resistance from management. However, because SouthWest is a large system, providing case manager services would likely provide a positive return on investment by reducing the costs associated with readmissions and complications
Concluding Remarks The questions related to making changes for the SouthWest system and the dialysis clinic are difficult to answer without more information. Without knowing anything about SouthWest s current quality initiatives and available resources, we are uncomfortable suggesting a formal framework for testing and implementation. An improved IT infrastructure including decision rules to monitor and flag at-risk patients or unusual test results would greatly improve the quality of care for Carla and patients worldwide. Being able to access real-time information that connects all aspects of the care and includes a variety of human factors and system redundancy considerations would help improve the rate at which patients receive the appropriate care. Such a system will take years even a single facility can have multiple IT systems that do not interact. However, we are confident that better communication between facilities, a case manager to coordinate care, and improved patient education are feasible changes that could potentially be made quickly and inexpensively by SouthWest and the dialysis clinic now.