Post on 20-May-2020
MLC Annual Healthcare Lean Symposium
October 10 2014
Brian Vander Weele Senior Process Engineer
Leveraging Lean Process Improvement
Methodology to Enhance Patientrsquos
End of Life Care
Spectrum Health Hospitals at a Glance
Not-for-profit health system based in West Michigan
Comprised of 11 hospitals (over 1370 licensed beds)
Includes physician group totaling more than 1000 providers
Priority Health Plan with over 575000 members
Over 21000 employees
Background
In further analyzing inpatient mortality rates the Quality
Department discovered the following
Chart reviews indicated that Spectrum was not consistently
identifying patients with end stage disease or appropriately
facilitating discussions about treatment options
Inpatient mortality data indicated
Average age was 71 years old
27 of inpatient deaths had transfered to Inpatient Hospice
67 of inpatient deaths had end stage disease
Average of inpatient days in 6 months prior to death was 125
End-of-Life ldquoWishesrdquo Care
What Patients Want
Majority of Americans prefer to die at home
(Hays et al 2001 Gallup 2000)
Pain-Free Passing
What Patients Get
335 die at home (2009 Teno et al 2013)
Patients continue to die in pain
(Meier 2006)
The Dilemma Challenge
Providing What People Need (or Want) Is Often
Different From What We Naturally Want To Do
This is especially true in healthcare as it relates to end of life
care ndash hence the cultural clash of ldquobias to treatrdquo vs
considering patientfamilyrsquos end of life wishes
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Spectrum Health Hospitals at a Glance
Not-for-profit health system based in West Michigan
Comprised of 11 hospitals (over 1370 licensed beds)
Includes physician group totaling more than 1000 providers
Priority Health Plan with over 575000 members
Over 21000 employees
Background
In further analyzing inpatient mortality rates the Quality
Department discovered the following
Chart reviews indicated that Spectrum was not consistently
identifying patients with end stage disease or appropriately
facilitating discussions about treatment options
Inpatient mortality data indicated
Average age was 71 years old
27 of inpatient deaths had transfered to Inpatient Hospice
67 of inpatient deaths had end stage disease
Average of inpatient days in 6 months prior to death was 125
End-of-Life ldquoWishesrdquo Care
What Patients Want
Majority of Americans prefer to die at home
(Hays et al 2001 Gallup 2000)
Pain-Free Passing
What Patients Get
335 die at home (2009 Teno et al 2013)
Patients continue to die in pain
(Meier 2006)
The Dilemma Challenge
Providing What People Need (or Want) Is Often
Different From What We Naturally Want To Do
This is especially true in healthcare as it relates to end of life
care ndash hence the cultural clash of ldquobias to treatrdquo vs
considering patientfamilyrsquos end of life wishes
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Background
In further analyzing inpatient mortality rates the Quality
Department discovered the following
Chart reviews indicated that Spectrum was not consistently
identifying patients with end stage disease or appropriately
facilitating discussions about treatment options
Inpatient mortality data indicated
Average age was 71 years old
27 of inpatient deaths had transfered to Inpatient Hospice
67 of inpatient deaths had end stage disease
Average of inpatient days in 6 months prior to death was 125
End-of-Life ldquoWishesrdquo Care
What Patients Want
Majority of Americans prefer to die at home
(Hays et al 2001 Gallup 2000)
Pain-Free Passing
What Patients Get
335 die at home (2009 Teno et al 2013)
Patients continue to die in pain
(Meier 2006)
The Dilemma Challenge
Providing What People Need (or Want) Is Often
Different From What We Naturally Want To Do
This is especially true in healthcare as it relates to end of life
care ndash hence the cultural clash of ldquobias to treatrdquo vs
considering patientfamilyrsquos end of life wishes
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End-of-Life ldquoWishesrdquo Care
What Patients Want
Majority of Americans prefer to die at home
(Hays et al 2001 Gallup 2000)
Pain-Free Passing
What Patients Get
335 die at home (2009 Teno et al 2013)
Patients continue to die in pain
(Meier 2006)
The Dilemma Challenge
Providing What People Need (or Want) Is Often
Different From What We Naturally Want To Do
This is especially true in healthcare as it relates to end of life
care ndash hence the cultural clash of ldquobias to treatrdquo vs
considering patientfamilyrsquos end of life wishes
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
The Dilemma Challenge
Providing What People Need (or Want) Is Often
Different From What We Naturally Want To Do
This is especially true in healthcare as it relates to end of life
care ndash hence the cultural clash of ldquobias to treatrdquo vs
considering patientfamilyrsquos end of life wishes
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
How did Spectrum Health Approach This
Used a structured approach known as Value Stream
Analysis to identify improvement opportunities
Included patient and family advocates in our workshops
Developed a process for identifying patients with chronic
life-limiting illness that might benefit from an end of life
conversation about treatment options
By trialing improvement ideas ndash and changing the culture
one patient one physician at a time
Utilized Palliative Care to assist patients and families to
understand options and define their wishes
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Value Stream Analysis Approach
Based on lean thinking and the Toyota Production System
Value must be specified from the patientrsquos point of view
Focuses on making it better not perfect
Donrsquot Delay - A 50 solution today is better than an
85 solution six months from now
Value Stream ndash flow of all activities or
processes that provide care to the patient
Value Stream Analysis ndash structured approach
for planning and linking improvements
together within the value stream
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Steering Team
Responsibilities
Governance structure to manage improvement
Determine Areas of Focus (VS Vision)
Establish TargetsMeasurement Systems
Remove Organizational Barriers
Create Accountability and Sustainability
Leadership Standard Work Auditing
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life Care Steering Team
Membership included Executive Sponsor and Physician
Champion a Process Owner Process Improvement
Engineer and other key stakeholders (6-12 members)
Reviewed status of key metrics progress on previous
improvement RIEsProjects planning for future RIEs etc
Weekly meetings
Monthly review of
Mission Control
Board
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
A3 Thinking
A structured cycle of improvement
Framework for organized thinking
Confirmed State
Experiments
Hypothesis ndash
ifhellipthenhellip
Gap Analysis
Future State
Current State
Business Case
Lessons Learned
Completion Plan
Can be used for
Strategy Deployment
Value Stream
Analysis (VSA)
Rapid Improvement
Events (RIE)
Problem Solving
Personal
Development
9 block approach
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Improvement Process Centers Around ldquoWhat Ifrdquo
What if
We helped patients identify what their wishes are
Instead of Automatically assuming that patients and families
want full treatment ndash after all they showed up at the
hospital right
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Workshop
Typically a 3 day planning event ndash follows the A3 format
Day 1 ndash Analyze the Current State
Day 2 ndash Define the Ideal and Future State
Day 3 ndash Develop Action Plan and A3rsquos
Main deliverable is a prioritized Action
Plan for the next 12 months
BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14
RIE
PR
OJ
EC
TS
Just-
Do-It
Just-
Stop-It
See Action Plan for
details
Improve the Technology RIE
Provide better end of life care Discharge Instructions RIE
Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit
Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)
Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits
Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC
Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit
Evaluateopportunities to implement a pre-screening process with SH Direct
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Participants
Patient Family Advisory Council Member
Fresh Eyes
Value Stream Owner
Executive Sponsor
Physician ndash Palliative Care
Physician ndash Hospitalist Group
Physician ndash Acute Care
Director ndash Emergency Services
Nurse Manager ndash Observation Unit
Supervisor ndash Billing
Representative from Hospice
Director of Nursing Practice
Manager of Advance Care Planning
Quality Data Analyst
Senior Analyst ndash Compliance
Manager ndash Coding
Clinical Ethicist
Process Engineer
PI Coach
Sensei
1013 1113 1213 114 214 314 414 514
RIEs
Pro
ject
s
Just
Do-Its
(or
Stop-
Its)
Indicates Complete Indicates Future Plan
EOL ACP RIE
Trigger Tool on
SCCU amp ACE units
Operationalize
AD Patient Wishes (ACESCCU)
Patient Education
upon DC (ACE)
Util ization of
CMMSW (SCCU)
Provideappropriate
education for ED Physicians Hospitalists
Residents RNs and staff
TRIGGER
TOOL PILOT(Nov 12 -Dec 12)
ED 4-West
Obs Unit
Improve the
Technology
Electronic Trigger
Tool Notification of prev PC consult
Pilot the Trigger Tool
at United
Hopital
Develop EOL
Dashboard
Education Plan for Physicians amp Staff based
on Pilot Results
Informal - ongoing)
Develop an
Overall Education Plan
w subject matter experts
(3 yr plan)
- coordinate with
Bris project timeline
Action
Plan
End of Life Care VSA Workshop (Sep 4-6 2013)
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life Care VSA Workshop (Sep 4-6 2013)
Business Case Chart review of recent
mortalities indicates that Spectrum
Health is not consistently identifying
patients with end stage disease or
appropriately facilitating discussions
about treatment options
Ideal State
Future State
Provide best practice evidence based
end of life care as described by the
Gundersen Lutheran model IHI etc
Provide appropriate tools
1) To identify appropriate patients
2) For caregivers to feel comfortable to
have the conversations regarding
end of life treatment plans
3) To document those treatment plans
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life Care VSA Workshop (Sep 4-6 2013)
If we Identify patients
who are at end of life
earlier in our process and
provide appropriate
resources for decision-
making
Then we Have a
greater chance of providing
the type of end of life care
that the patient and family
desires
Box 5 Hypothesis
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)
Improving Recognition amp Care of Patients with End-Stage
or Life-Limiting Illness Who are Appropriate for a
Palliative Care Consult to Discuss Treatment Options
No simple quick tools in existence yet
so Spectrum Health developed our own
ldquotrigger toolrdquo
Piloted the form in ED and a MedSurg
unit supported by Hospitalist Group
Patients 65 and older with one or more
EDinpatient encounters in past 6
months eligible for Pilot
Follow guidelines on form
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Results of the Trigger Tool Pilot
411 Trigger Tool Forms Initiated
6 Palliative Care consults generated
Was this a failure
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
First Patient in the Pilot
85 yr old woman with metastatic kidney disease admitted
to observation for dehydration failure to thrive
Palliative Care consulted saw patient win 12 hrs of arrival
on the unit Had a family meeting - worked through issues
Patient sent home with hospice that evening
Success
Had been significant discord between patient and family
Able to facilitate a conversation in the Observation Unit
Patient got what she wantedneeded without needing to be
admitted to the hospital
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Another Success Story
77 year old woman presented to the emergency department with
widespread kidney cancer dehydration and poor nutrition
Using the new trigger tool the ED notified the palliative care team
The team scheduled a family meeting where the patientrsquos goals
wishes and preferences for care were discussed
The conversation resulted in the patient amp family mutually deciding
the best course of care was to enroll the patient in SH Hospice
Later that evening she returned to her home and received
appropriate supportive end of life care
Had this patient not been identified she would have been hospitalized
and may have undergone significantly more aggressive care and suffered
a long hospitalization inconsistent with her wishes
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Challenges Encountered During the Pilot
Societal norms related to death and dying plus physician
and healthcare organizational culture are our biggest
barriers ndash much misunderstanding inconsistent language
etc
Tendency to jump to treatment rather than evaluating
frailty
Maybe the ED isnrsquot the best place to begin to change the
bias to treat culture ndash admitting services
Did we place to much emphasis on the physician to
recognize these end of life patients ndash whole care team
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Structure for Improvement
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Rapid Improvement Event (RIE)
Typically a 4 day event (follow A3 format)
Day 1 ndash Analyze the Current State
Day 2 ndash Determine Future State amp Hypotheses
Day 3 ndash Run Experiments
Day 4 ndash Develop Standard Work
Small team of people focused on improving a part of a
value stream
Begin to change the culture so that
ldquochanges can happen dailyrdquo
Design test amp implement improvements (results) by the
end of the activity (week)
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life ACP RIE (Jan27-30 2014)
Business Case Chart review of
recent mortalities indicates that
SH is not consistently asking or
operationalizing the
patientfamily wishes for
treatment of patients who are
admitted with an Advance
Directive or who have a chronic
life-limiting illness Patients are
offered treatment before the
clinician assesses what the
patientrsquos wishes goals and
preferences are rather than
offering all available options
Scope Patients admitted to
SCCU and ACE Units
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life ACP RIE (Jan27-30 2014)
Future State
Spectrum Health will have the following in place for patients
with chronic life-limiting illness
Method for identifying these patients (at admission or during
daily assessments) that would benefit from a Palliative Care
Consult earlier in the patientrsquos stay
Provide Education and DC Instructions regarding importance
of ADDPOAH amp life-limiting illness
Standard Work documenting Care Plans with meet Advance
Directives and patient wishes ndash that readily transfer to PCP
and provide alerts for future ED visits and admissions
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Trigger Tool
Early identification of
patients who could
benefit from Palliative
Care consult
Good opportunity to
discuss and
document patientrsquos
wishes
Standard Work
Interdisciplinary
Rounds
End of Life ACP RIE ndash Experiments SCCU
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Trigger Tool ndash similar to SCCU
Discharge Education
Standard Work for providing
patients with resources related
to ADamp ACP upon DC
Reinforce importance of having
ADDPOAH
Standard template for
Discharge Progress Note ndash to
carry over to future encounters
Initiate MDI
End of Life ACP RIE ndash Experiments ACE
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
1 appropriate Intervention for ptfamily
Trigger Tool used for 7 patients in SCCU
ndash 2 resulted in Palliative Care Consults
Care ManagerMSW attended 7 of 7
patients on SCCU rounds
6 of 11 patients ldquotriggeredrdquo for PC
consult during I-Rounds on ACE unit
ACE Unit able to provide AD packet to
patient upon discharge
1 opportunity for standard template RN
discharge note regarding patient wishes
Develop an
appropriate process
to fully understand
the patientrsquos wishes
Provide care
according to the
patientrsquos wishes
End of Life ACP RIE - Day 3 Results
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Before and After (RIE Patient Story)
83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior
Was extubated for a day and now declining again ndash needed re-intubation within hours
During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified
son (DPOAH)
Husband and son indicated that patient previously expressed that she did not want to
be on ldquolife supportrdquo No clear understanding of choices presented to them
Once husband and son understood what being put back on the ventilator really meant
ndash they elected comfort care and did not re-intubate the patient
Hospice there within a couple of hours
BEFORE
In the confusion of medical terminology ndash
patient would have been re-intubated
Patient would likely have been on the
ventilator for many days (in hospital or
LTC facility) contrary to her stated wishes
Eventually patientrsquos family would have to
decide to take patient off the ventilator
AFTER
Re-addressing goals in a timely fashion
allowed the ICU team to better
understand the patientrsquos wishes
Patient passed away peacefully that night
with family at the bedside
Intervention allowed team to support the
patientrsquos wishes support the family and
ensure a peaceful death
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
End of Life ACP RIE (Jan27-30 2014)
Before Provider Focus ndash ldquoBias to Treatrdquo
After Patient Focus (PFAC)
Clear description of options (What are my choices)
More education on importance of having ADDPOAH for
patients and family
Get Patient Education and DC Instructions to patient amp
family earlier ndash not when going out the door at discharge
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
VSA Structure for Improvement (Sustain)
Value
Stream
Analysis
Workshop Develop
Prioritized
Action
Plan 4-day
Rapid
Improvement
Events (RIE)
Standard
Work
VSA Steering Team
Managing
For Daily
Improvement
(MDI)
Kamishibai
Audit
Process
A3 Thinking
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Sustaining the Improvements ndash VSA RIE
Impro
ve
men
t
Gains
Standard Work
MDI (Managing for Daily
Improvement)
Kamishibai Audits
Leadership
Standard Work
Time
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
The currently known best method to perform the work
A living document
Standard Work
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Managing for Daily Improvement (MDI)
MDI is a system for managing and sustaining process
improvement initiatives
Major Components of MDI
Visual Management Boards
Performance Tracking
Daily Huddles
Daily Problem Solving
Daily Assessments
Daily Gemba Walks
Daily Standard Work for all Roles
Can you tell in 5 seconds whatrsquos going on
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Kamishibai Auditing
Visual Audit Cards are the foundation
of the Kamishibai System
Cue cards for auditing a process
Ensure that a new process is routinely followed (accountability)
Can be used hourly daily or weekly
Audits need to be short (lt 5 minutes)
Audits need to be valuable ndash critical few vs important many
Fostering a culture that takes real time corrective action
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Kamishibai Audit Board
Used as simple
and effective
visual control in
performing daily
process audits amp
assessments of
Standard Work
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Audit Question(s)
Audit Details
Corrective Action Details
Name of Audit
Instructions
Audit Cards
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Ongoing Results ndash Palliative Care Consults
Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug
BW 94 100 114 89 98 108 100 90 109 98 140 125 125
BL 20 23 32 20 27 19 23 21 28 42 21
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Co
nsu
lts P
er
Mo
nth
No Pilot conducted at Blodgett
End of Pilot
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Ongoing Results ndash Admit Order to PC Order
0
5
10
15
20
25
30
35
Admit Order to PC Order - Butterworth (Days - median)
RIE 1
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Ongoing Results ndash Admit Order to PC Order
00
10
20
30
40
50
60
Admit Order to PC Order - Blodgett (Days - median)
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Ongoing Challenges ndash Countermeasures
Increase Hospitalistsrsquo
engagement amp understanding
Confusion among staff
between Palliative Care and
Hospice
Providers not comfortable
ldquohaving the conversationrdquo
Need to spread to many other
units in hospital
Paper ldquotrigger toolrdquo requires a
lot of ldquoupkeeprdquo
Have Physician leadership
round and do Lunch amp Learns
Provide better education for
staff to understand the
differences
Provide scripting for staff with
the education amp training
Follow implementation of
multidisciplinary rounding
Build an electronic ldquotrigger
toolrdquo
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Palliative Care The Right Thing To Do
Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo
Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction
Aggressive symptom management vs curative management
Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
Deciding how someone will spend the time they have left is not our decision to make
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Summary of Benefits
A greater number of patients and families are becoming better
informed about their end of life care options
Increased awareness about scope of service and support that
Palliative Care can offer to patients and clinical care team
Communication about patient wishes (advance directives) is
increasing among providers caring for them
Patientrsquos end of life options are presented their wishes are
discussed properly documented amp carried out by providers
Increase patientfamily satisfaction regarding end of life care
Reduce Length of Stay with earlier PCHospice consults
Reduce total cost of care with less aggressive caretreatments
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Lessons Learned
Having a structured process for working through all the issues
and ideas was very helpful and provided a quality process
This is a very personal and emotional process
This topic is very complex with lots of passionate ideas from
providers
Data and personal stories are both necessary to effectively
change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet
the patientrsquos desiresrdquo
Must be patient focused and not cost driven ndash itrsquos all about
providing the right care at the right time per the patientrsquos
informed wishes ndash no more and no less
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements
Next Key Steps
Develop amp implement Goals of Care Form
Scan hard copy of AD into patient chart in ldquoreal timerdquo
Create electronic ldquotrigger toolrdquo
Education amp Training for Providers to become comfortable having
ldquothe conversationrdquo to provide options and obtain patientrsquos wishes
Develop method(s) to document amp communicate patient wishes
PC consults etc to next encounter patientrsquos PCP andor
Nursing Facility
Develop strategy for spreading the experimentspilots to other
inpatient units following the deployment of multi-disc rounding
Continue to develop MDI in units to sustain the improvements