Wolfson Children s Hospital Jacksonville, Florida

Transcription

1 The Use of Advanced Technology to Improve Patient Safety and Flow in a Children s Hospital Wolfson Children s Hospital Jacksonville, Florida Sharon Simmons, MSN, RN, CPN Abby Sapp, BSN, RN, CPN Pediatric Nursing Annual Conference, July 2015 Pediatric Health Care Partners Wolfson Children s Hospital 213 licensed beds 11,522 children hospitalized 11,359 surgeries 68,539 visits to our Emergency Centers 80,000+ individual patients 1,300+ emergency transports Soon to be trauma designated, early 2016 BMTU per year OPEN Heart program, 300 open cases ECMO 20 cases per year Magnet Recognized 3 rd re-designation in 2016 Wolfson Children s Hospital The Use of Advanced Technology to Improve Patient Flow and Safety in a Children s Hospital Jacksonville (Primary) and Secondary Service Areas Specialty Center Peds Cardiology Objectives: 1. State three examples where the use of advanced technology to report real time patient data impacts safety and provides open, transparent communication. Wireless communication using VOCERA Development of Census and Safety report Use of WebEx at shift change 2. Discuss the impact of a Patient Flow Team and Daily System Discharge Report on key patient flow metrics. OUTREACH PROGRAM 3.

2 Advanced Technology to Improve Patient Safety The initiative/project implemented three specific strategies: 1. VOCERA for real time communication with families, physicians, ancillary departments, and staff-to-staff 2. Design and implement a census and safety report 3. Shift huddle/conference call twice daily, 7 days/week Link between SAFETY and communication One study revealed 80% of medical errors involve miscommunication 1 National Patient Safety Goal : Improve Staff Communication 2 Improving communication also affects staff satisfaction and patient satisfaction 1. Woolf, S. H., Kuzel, A. J., Dovey, S. M., & Phillips, R. J. (2004). A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Annals Of Family Medicine, 2(4), The Joint Commission. (n. d.) National patient safety goals effective January 1, Retrieved from Impetus for Change NDNQI Survey results in Fall 2014 Mean score 4.7; our score 4.99 out of 6 About VOCERA Hands free badge Operates on Baptist Health wireless network Implemented Summer, 2014 User logs in with first & last name Abby Sapp Wolfson 4 Nurse Who uses VOCERA? Implementation Process At time of implementation, badge wearers include Floor RN s Nursing assistants House Supervisor Nurse managers Vascular access team Child Life Specialists Most often, VOCERA users call other VOCERA users by name (first and last) Limits ability to contact others, if their full name is unknown Built in capability to call in to VOCERA network from a phone

3 Implementation Process Profiles within VOCERA Train RN s to add their room assignments to VOCERA each shift Abby Sapp Wolfson 4 Nurse 416 Nurse 417 Nurse 418 Nurse 419 Nurse Continuously encourage use of VOCERA Room Assignments and troubleshoot process issues Demonstrate how physicians can place call to VOCERA badge from telephone Calling from Phone Results Improved MD-RN communication reduces delays in care Day shift RN leaves at end of shift, forgets to report about occurrence during shift; can reach night shift RN on VOCERA Parents/family can call for update from home, be transferred directly to RN HIPPA concerns Physician Speaks to Use of VOCERA Accessibility of Information Increasing Safety Integration of Technology Accessibility of information Safety

4 Census & Safety Data Report Census and Safety Data Report Conceptualized by VP Patient Care Services Developed by Manager of House Supervisors Many revisions! Distributed at 0600 and 1800 EVERY day Census & Safety Data Report CSDR - Census Distribution includes stakeholders throughout hospital Hospital President VP of Nursing Pharmacy Physicians Nursing Directors Nurse Managers House Supervisors Environmental Services Compares census to capacity; able to highlight where RN:PT ratios are higher than usual CSDR - Assignments CSDR - Culture of Safety Elaborates on RN:PT ratios, highlights charge nurse assignments and potential discharges. High acuity patients and potential safety issues are addressed.

5 CSDR - ED/Holding/Shift Leaders CSDR - Staffing & OR Forecast Current ED Census helps predict admissions to floor. Shift leader contact information available in one place. Staffing numbers available, including house-wide floats. Planned surgery cases outlined. CSDR - Dynamic Tool Conference Call Not just a static spreadsheet - Guides the shift conference calls 2x/day where focus is SAFETY! Keeps the hospital leaders focused on our patients and promotes unity of purpose. Cisco WebEx platform used to complete conference call at 0715 and 1915 every day Led by House Supervisor (ADON) with oncoming and off going charge nurses also participating. Conference Call Example Manager Perspective of Census and Safety Report TRANSPARENCY

6 The Use of Advanced Technology to Improve Patient Flow and Safety in a Children s Hospital Advanced technology improving patient flow Sharon Simmons, MSN, RN, CPN Problem: Advance Technology to Improve Patient FLOW Patient arrivals and discharges were not aligned until later in the day. Supply of beds did not meet the demand until after 5pm % of discharge orders placed before noon were only at 21-31% % of discharges within 90 minutes of order written were only at 38% Discharge Project - PROBLEM Discharge Project - PROBLEM Baseline Data: Wolfson Patient Flow Team Operational Performance Improvement (OPI) Wolfson Patient Flow Team Emerging Leaders Project The Emerging Leaders Initiative is a one-year process to prepare employees for supervisory positions. Emerging Leaders build leadership skills of high potential nonmanagement or assistant management employees. Over the course of the year, participants build fundamental management skills. They will have an opportunity to demonstrate these skills on project teams and committees.

7 Wolfson Patient Flow Team TEAM MEMBERS, Roles and Responsibility Discharge Project - GOALS Name Role Responsibility VP of Operations and Project Champion Communicates vision & provides resources Patient Care Services Removes barriers to success OPI Lead and Project Managers Oversees project planning and implementation Emerging Leaders (5) Monitors & documents progress Communicates results Pilot Manager Operational Owner Handles the operations involved with the project Serves as the liaison between nursing staff and the project team Physician Key Physician Champions Handles the operations involved with the project Stakeholders Serves as the liaison between physicians and the project team Nursing Director Nursing Champion Serves as the liaison between nursing and the project team House Supervisor Team Member Participates in team meetings and completes assigned action items GOALS : By July Align bed supply and demand to meet earlier in the day before 2 pm 2. Increase the percentage of final discharge orders placed before noon to 60% 3. Increase the percentage of D/C order to actual discharge to 60% within 90 minutes Pilot Unit Baseline OPI Tools Completed SIPOC (Supplies, Inputs, Process, Outputs, Customers) Detailed Flow Chart Cause and Effect Diagram Cause and Effect Multi-vote Cause and Effect Matrix Pareto Chart of Discharge Delays Control Chart of Daily Metrics Data Source : Cerner Millennium Flow Chart Cause and Effect

8 Reasons for Delays 102 Patients No patterns identified Pareto of Cause and Effect Results Diagnosis ALOS Asthma 1.2 Bronchiolitis 1.8 URI 1.7 RSV 2.0 Pneumonia 4.0 Pareto Chart of Delay Improvement Process Changes Daily huddle at 9am with RN / MD on unit Mon-Fri (5-10min) Manager post control chart from day before in graph and report results at daily huddle (MD=D/C before 12noon; RN=D/C<90min) Nurses required to send to MANAGER with patient s MRN # and the reason discharge was > 90 min Hospitalists committed to writing orders after huddle on patient s ready for discharge before rounds with Residents Improvement Process Changes Improvement Process Changes The ANM presents a census list of anticipated discharges for the day. Goal is to have the MD write the orders before their daily rounds Night shift RN s to assess all anticipated discharges and pass that information in shift change report to ANM Development of Daily and Monthly Discharge Dashboard Metrics by Unit, MD, RN Research tab highlights those instances where discharge took longer than 90 minutes from the MD order Create a separate tab for the Hospitalist monitoring metrics (majority of discharges) Report results at monthly Steering Committees

9 Daily Huddles Improvement Process Changes RN % MD - 42% RESULTS Baseline Data - Review Pilot Unit Outcomes Pilot Unit Cumulative Admissions and Discharges by Hour of the Day February 2014 n = 255 Outcomes PEDS ED Review of the PAST 3.5% LWBS Peds ED 3.0% 3.0% 2.9% 2.5% Percentage 2.0% 1.5% 2.2% 2.1% 1.8% 1.4% Series1 1.0% 1.0% 0.5% 0.6% 0.0% Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15

10 Review of the PAST Current System Outcomes Hospital Unit Description Outcomes One year later Unit Type n (total) %of Discharge Order to Discharge within 90 min % of Total Discharge Order Before 12noon % of Total Discharge Order Before 2:00pm WCH W-W4 - Wolf 4 Medicine % 48% 51% WCH W-W5 - Wolf 5 Neuro % 48% 39% WCH W-W6 - Wolf 6 Surg/Ortho % 37% 39% WCH Weaver - Hem/Onc WCH Wolfson MedSurg Oncology % 41% 31% ALL % 40% 42% Daily Metrics Daily System Discharge Report Summary Daily System Discharge Report Summary (See attached) Inpatient and Observation Saturday, June 27, % 60% 60% Home % of Discharge Order to % of Total Discharge % of Total Discharges % of Total Discharges Hospital Discharge within 90 n Orders Before 12:00 PM Before 2:00 PM Home min** Jacksonville % 53.1% 35.4% 86.2% South % 34.5% 43.3% 80.0% Beaches % 26.3% 45.0% 80.0% Nassau % 40.0% 30.0% 100.0% Wolfson % 45.5% 58.8% 100.0% *Excludes instances where the discharge order was placed after 9:00 pm or before 7:00 am **Labor and delivery patients excluded from the summary but may still be found at the unit-level. Color Key* Meeting current target Greater than 75% towards target Less than 75% towards target *n = discharges with a time/stamp MAY 2015 Current and Future State Barriers Morning discharge huddles have become common practice Metrics sent every Monday to Med Surg Nurse Managers and Chief Hospitalist for ongoing results Daily System Discharge Report Summary continues to be sent out every morning at 6am, 365 days a year!! Resident Team assignments changed based on project Resident teams change monthly Have RESIDENTS not only from University of Florida, but receive rotations from Family Practice and from US Navy Need to educate and the beginning of each month Hospitalist Attending's change frequently as well, sometimes day to day, and some are better than others! RN and MD have their own metric and they don t always match!

11 Lessons Learned Questions PROCESS OWNER engagement is crucial to sustained success Usefulness of daily real-time data presented to interdisciplinary team Broader awareness of patient flow and how each discipline contributes to timely discharges Questions?