Transcript Out to Lunch

“Out for lunch”
Discharge Planning
Clivena Ngatai, Helen Thomas, Olivia
Woodman, Jacqui Wynne-Jones,
Institute for Healthcare Improvement
Content and Aim
What is the name of this project or its content area?
“Out for Lunch”
Aim Statement(s) for this project
Create capacity by avoiding discharge delays in the pilot group ( surgical) at
MMH, and decrease average LOS by increasing the discharges before 3pm by
20% by April 30th 2013 and 30% by August 31st 2013.
“Out for Lunch”
Primary Drivers
Secondary Drivers
Secondary Drivers
Driver Diagram-v3
Ideas
Date: 5 December 2012
MOH targets
Population
growth
Measures:
1. LOS
2. Readmission
3. GDD
4. Pt satis
Saving 20,000
bed days
EC
Admission Process
Timeliness of
documentation
Quality of
documentation
Coordination
plan of care
Measures:
1. Completed dx
tool
2. GDD
3. Timeliness of dx
First draft date
14 Sept
Measures:
1. Readmission
2. Nurse led dx
3. Staff satis
4. LOS
Std wknd plan-Dx info
in one place with
reasons
Discharge checklist
Winter workload
Delayed
discharge
Variation in
practice
Weekend rounding
Co morbidities
First “Do no
Harm”
Pt to have Dx date & time
Patient and whanau
centred care
Nurse led
discharges
Patient /Transition
lounge
Access to
Diagnostics
Pharmacy
Health literacy
Pilot nurse led discharge
Ward rounds
Effective handover
Electronic
checklist
Risk
Management
Patient awareness
on GDD
PT self mgmt
MDT inclusion
Create capacity by
avoiding discharge
delays in the pilot group
at MMH, and decrease
average LOS by
increasing the discharges
before 3pm by 20%
before April 30th 2013
and 30% by August 31st
2013
Ticket for Discharge
Handover of
primary care
Combined EDS for all service
(MDT led Dx)
Change Concepts & Ideas for PDSAs
Idea for Testing in a
PDSA
Goal Discharge Date
Start: 17th December 2012
Theory and prediction about what will happen
when you test this idea
Theory: 0% of surgical patients in the pilot ward will
have documented goal discharge dates on
admission for care.
Prediction: As from 17th December 2012 – 14th
January 2013, 2 patients ( at any one time ) on the
pilot ward and under the care of one SMO, will have
a documented goal discharge date (involving the
patient, whanau and MDT)
December period – scoping – fewer process’ to interrupt
Choosing Patients – ethnicity, admission time, acute /elective or random
Problem: No documented Goal Discharge Date for patients
Aim of this change: To create an awareness of the planned Goal Discharge Date for the patient and
their family, nursing staff and all MDT.
The Change:
Redo PDSA
18/12/13
ACT:
Abandon
STUDY:
Investigated when Mr
Kenealy was rostered
to operate again.
Rostered on for acutes
18/12/12
PLAN:
For all of Mr
Kenealy’s patients
on Ward 35N to
have GDDs set on
admission.
To eventually be
rolled out to all
patients on Ward
35N and managed
by the nursing staff
Measurement
• Patient
satisfaction
•Staff satisfaction
•Length of Stay
•Whether or not
GDD was met.
DO:
Set a GDD for one of
Mr Kenealy’s patients
on 17/12/12.
Unexpected
Problem – no
patients of Mr
Kenealy’s currently on
Ward 35N
Prediction: All patients in 35 N and under care of Mr Kenealy will be set goal discharge dates on
admission. Once date is set a plan and checklist will be implemented for all of the team including
the patient and family to maintain focus.
Goal Discharge Date
Welcome to Ward 35N
Your Goal Discharge Date & Time is
________________________________
Your Nurse today is _______________(_____)
The Ward Charge Nurse is _________________
Your Surgical Team is ______________________
Your Key Family Member is __________________
Revised Goal
Discharge date
Welcome to Ward 35North
My Goal discharge date and time is
_______________________________
My Nurse today is______________________
My Ward CN is_________________________
My Surgical Team is_____________________
My Key family member is__________________
Problem: No documented Goal Discharge Date for patients
Aim of this change: To create an awareness of the planned Goal Discharge Date for the patient and
their family, nursing staff and all MDT.
The Change:
•Introduction of GDD
chart at head of bed to
continue.
ACT:
Adopt
Adapt
•Continue with GDD
chart for Mr Kenealy’s
patients on Ward 35N.
• Plan for discussions
with ward staff
regarding nurse led
setting of GDDs
STUDY:
PLAN:
For all of Mr
Kenealy’s patients
on Ward 35N to
have GDDs set on
admission.
To eventually be
rolled out to all
patients on Ward
35N and managed
by the nursing staff
Measurement
• Patient
satisfaction
• Staff satisfaction
• Length of Stay
• Whether or not
GDD was met.
DO:
•Staff were on-board and Who: Project Group
focused on working
What:Meet with patient on ward
towards GDD
35N, explained process and set
•Patient was discharged a GDD in collaboration with
day earlier than the GDD patient and surgeon.
Learning: Communication When:18/12/12
created focus and
How: GDD documented
raised awareness
in notes and on chart
at head of patient’s
bed
Prediction: All patients in 35 N and under care of Mr Kenealy will be set goal discharge dates on
admission. Once date is set a plan and checklist will be implemented for all of the MDT as well as
the patient and family to maintain focus.
Discharge checklist
• Getting Ready for Home
Checklist of Input Required before Discharge
Physio Req
Yes/No
Cleared for Discharge Yes/No
OT Required
Yes/No
Cleared for Discharge Yes/No
Social Worker Yes / No
Cleared for Discharge Yes / No
Pharmacy Review Yes/No
Cleared for Discharge Yes / No
District Nursing Yes / No
Referral Completed Yes / No
Story board Feed back display for
ward staff piloting GDD
22 December
“Out for Lunch”
Driver Diagram-v4
Primary Drivers
Secondary Drivers
Secondary Drivers
Date: 7 March 2013
MOH targets
Population
growth
2nd draft
8 March
Measures:
1. LOS
2. Readmission
3. GDD
4. Pt satis
Saving 20,000
bed days
EC
Admission Process
Timeliness of
documentation
Create capacity by
avoiding discharge
delays in the pilot group
at MMH, and decrease
average LOS by
increasing the discharges
before 3pm by 20%
before April 30th 2013
and 30% by August 31st
2013
Ideas
Pt to have Dx date & time
Std wknd plan-Dx info in
one place with reasons
Ticket for Discharge
Combined EDS for all service (MDT
led Dx)
Weekend rounding
Measures:
1. Completed dx
tool
2. GDD
3. Timeliness of dx
PT self mgmt
Measures:
1. Readmission
2. Nurse led dx
3. Staff satis
4. LOS
GDD piloted on Ward 35N
Winter workload
Delayed
discharge
Variation in
practice
Discharge checklist
Ward rounds
Patient and whanau
centred care
Patient awareness on
GDD
Effective handover
Co morbidities
Electronic
checklist
Risk
Management
Discharge beginning on
admission
Quality of
documentation
MDT inclusion
Coordination
plan of care
Implementation
phase
First “Do no
Harm”
Nurse led
discharges
Patient /Transition
lounge
Access to
Diagnostics
Pharmacy
Health literacy
Handover of
primary care
Pilot nurse led discharge
Draft 4 patient lounge in
progress for comments
Appreciation for a System
• MDT
• Emergency Care 6 hour target - MOH
• Other Campaigns – 20,000 bed days
Psychology
• Behaviour of staff
• Buy in / Willingness to change
• Expected not Inspected
Theory of Knowledge
• Clinical Experience
• Experiences of other organisations
• Family/patient centered care
• Goal Discharge Date focus
Understanding Variation
• Seasonal Effects – Holidays, summer vs
winter
• Annual Leave
• Outbreaks – Norovirus
• Patient Co-morbidities
• Surgical preferences
• Minutes on theatre acute list
Profound Knowledge Worksheet
12
Planning ahead
■ Check list for MDT -To be above the bed or in notes,
patient decision
■ Spread to more consultants in next couple weeks
■ Weekly Meetings, daily contact
■ Keep run chart up to date by collecting data
■ Add in time for discharge to checklist as 11.00 as
from 13th March.
■ Nurse Led Discharges for ward 35N – down the track
■Changes to the current EDS, by adding electronic
checklist