Unstoppable Report Removing a Barrier to Patient Flow by Nursing Process Redesign

Transcription

1 Unstoppable Report Removing a Barrier to Patient Flow by Nursing Process Redesign 17th Annual Society for Health Systems Management Engineering Forum February 12-13, 2005 Dallas, Texas

2 Norwalk Hospital New York - Boston NE Corridor 328 Licensed Bed Community Teaching Hospital, Level 2 Trauma Center ADC = 227 ~45,000 ED Visits per year Avg 24 admits daily from the ED Avg 15 admits daily from surgery

3 Norwalk Hospital Bed Team Sponsors: COO, VP Nursing Objectives: Improve management & utilization of beds, and patient flow leading to a reduction in length of stay (LOS) Start up January 2003

4 Process Improvement Tools Employed by Bed Team Root Cause analysis, Affinity Groups, Digraph, Pareto, Brainstorming Multiple efforts on a variety of fronts & by additional sub-committees led by Bed Team members

5 Report Improvement Team s Approach Understand the problem Define a specific goal Create pull to bring admissions in

6 I ll call you when the bed is ready

7 The old way Admitting assigned bed based on actual or anticipated discharges Unit Secretary (US) usually entered request to clean room in Teletracking system Sending unit would call (multiple times) to ascertain if the bed was ready US often had to walk to a room to check on bed availability

8 The old way Bed may be ready, but admitting RN was not More phone calls needed to catch receiving RN at a free moment Receiving RN may call back sending unit only to find that RN unable to give report

9 Report Improvement Team s process improvement approach Enlist staff support Flow diagram current and future processes Identify barriers Brainstorm solutions

10 Nursing Unit to Unit Report & Transfer Process, Previous State (<2004) START Emergency Department (ED) sends requisition to Admitting requesting inpatient bed assignment DELAY Admitting calls floor to obtain bed assignment Admitting calls ED with bed assignment Is bed ready? No ED Unit Secretary (US) or Nurse (RN) calls unit to ascertain bed availability Yes DELAY ED RN calls unit to give report Admitting RN available? No ED RN leaves message for unit RN to call back DELAY Yes Unit RN calls ED Report taken. Yes ED RN available? Patient Transport called by sending Unit No Unit RN leaves message for ED RN DELAY End Prepared by OI Dept., Nov. 25, 2003

11 START Nursing Unit to Unit Report Process Effective 12/03 ED sends requisition to Admitting requesting inpatient bed assignment Admitting calls floor to obtain bed assignment Admitting calls ED with bed assignment Is bed ready? Yes No ED Checks Teletracking system periodically until bed is listed as ready Benefit: Reduction in volume of phone calls to Admitting & assigned floor to check bed availability status. Benefit: standardization of content / reduction in variation ED RN calls report to the floor using template to structure content and order of information. Admitting RN available? No Other RN available on unit? Yes Report given to any available RN No Yes Report given to Patient Care Manager or Director on days or Clinical Nurse manager on 2nd and 3rd shifts Report passed to admitting RN if necessary Report taken. Time and person receiving recorded on template Benefit: Target and metric identified Patient arrives on unit within 30 minutes Template saved on the unit for data gathering and process control Benefit: Un-interruptable process. Reduction in delays waiting for hand-off Floors send completed forms to Nursing Staffing office for colation, data entry. Stafffing office reports data back to Nursing leaders on a monthly basis for feedback. End Prepared by OI Dept., Nov. 25, 2003

12 Insert photo of Liz Brice calling report to floor here? Combined photo?

13 Photo of RN on receiving floor here?

14 What s on the Report? Patient name, date, time Diagnosis Past Medical History Vitals Labs / Tests Medications System Status: Neuro, Respiratory, Cardiac, GI/GU, Vascular, Skin Social / Family History Transferring Unit RN, RN Taking Report, Time

15 Transfer Report TRANSFER REPORT Patient Name Age Date/Time Diagnosis/ Chief Complaint Code Status: Isolation: Allergies: PMH: Vital Signs: T- P- R- BP- Pulse Ox- Labs/Tests- Meds/Pain Mgmt.- Neuro Status: A&Ox3 Respiratory: WNL Cardiac: WNL GI/GU: WNL Diet: LBM: Vascular: WNL IV Access: Skin: D&I Mobility/Safety: Family/Social: Consults/Share Acute Care: Transferring Unit/ R.N. Ext. RN giving report Time pt arrived

16 Making report un-stoppable Teletracking monitors installed in ED, PACU, ICU and SCU so that sending units can check for bed availability without calling the unit Once bed is available, sending unit will call to give report

17 Will Scan Teletracking Screen Here

18 Making report un-stoppable The RN assigned to the patient on receiving unit takes report If he/she not available, next available RN takes report If the next RN is unavailable, the Care Manager or Director takes report

19 Benefits Increased quality of report Improved communication and trust between ED, Admitting, & Floors

20 Benefits Virtually eliminated problem of delays associated with waiting to give nursing report Measurable improvement (30 minutes) Better Knowledge = Better Care

21 Benefits Patients get to treatment faster Tension between departments is decreased Waiting time in ED is reduced

22 Benefit: Addresses One of the JCAHO s 2005 Hospitals National Patient Safety Goals 2005 Goal: Improve the effectiveness of communication among caregivers. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

23 Measuring the Process Forms require time notation Forms sent to Staffing Office coordinator who enters data into a spreadsheet and sends out a monthly report to nurse managers.

24 Time From Report given to Patient Arrival on Unit Median Target = 30 Minutes (December January 2005) 0:43 00: :36 00:35 00: Time (Minutes) 0:28 0:21 0:14 00:30 00:30 00:30 00:30 00:30 00:30 00:30 00: Volume of Forms Used ("N") 0: :00 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 0 Median Minutes Volume of Forms Used "N"

25 Average time from report to patient arrival (December January 2005) 01: :04 01: :57 Minutes 00:50 00:43 00:36 00:28 00:46 00:51 00:42 00:44 00:45 00: Denominator "N" 00: :14 00: :00 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 0 Average Minutes Denominator "N"

26 Top 4 sending areas using report (by percentage) 5 months, 2004 (N= 2,074) ED 59% PACU 26% Tele 6% ICU/CCU 3% 0% 10% 20% 30% 40% 50% 60%

27 Reasons for success Consensus that this was a problem Defined goal: 30 minutes Measurable: times on forms

28 Reasons for success Commitment by all parties involved The Right Thing to Do Senior Management support Solution created by those closest to the problem

29 Reasons for success Bed tracking software made available to ED, PACU, Telemetry Housekeeping personnel have no vested interest in holding a bed

30 Lessons Learned Culture change takes time: still occasional reluctance to take appropriate action Resistance to the new process was surprisingly low Process is less effective when occupancy exceeds 90%.

31 Tactics for Continued Success New staff members instructed in report process during floor orientation Regular monthly report and feedback at Nursing Management meetings Regular feedback at Nursing Leadership meetings

32 Comments / Questions