Quality Improvement Project Control Report Out · calls from other nursing units as opposed to...
Transcript of Quality Improvement Project Control Report Out · calls from other nursing units as opposed to...
Quality Improvement Project
Control Report Out
Prince County Hospital
Surgery Floor Lean Project
July 10th, 2014
Define
Health PEI’s ELT ( Executive Leadership Team ) identified the service
areas throughout the province for the LEAN projects. The primary
focus was to facilitate an overall decreased LOS (length of stay).
HPEI Surgery PCH Surgery
Staffed Beds Occ Rate 82.0% 93.4%
Budgeted Beds 56.0 20.0
Average Daily Census 44.1 18.7
ALC Avg Pts Per Day 0.8 0.4
% Pts ALC 1.9% 2.0%
Daily Num Pts Medically Discharged 0.7 0.4
ALOS (Acute Days) 6.0 6.7
Total Length of Stay (Days) 6.2 7.1
ELOS (Days) 4.8 5.5
Re-Admit Rate <= 7 Days 2.5% 2.3%
Re-Admit Rate 8 to 28 Days 3.7% 3.4%
Intra Transfer Pts Per Day 1.5 0.5
Pts Moved Per Day 0.8 0.5
CI ( Level 2 - 5) (3 mth rolling average) 9.7 3.7
Avg Med Error Rate (# per month) 0.0 0.0
Pd Hours As % Of Budget Hrs 130.70 137.06
Define
• Problem Statement
Our current process lacks communication, creates duplication, and
has undefined roles which results in staff dissatisfaction as identified
by feelings of being unsupported.
We want to foster a culture of a patient focused, multidisciplinary,
collaborative care team which will result in timely referral and
discharge processes.
Measure
• The time physio referral is sent to the time the assessment is
document.
• Measure the amount of times the ward clerk is required to do duties
off the unit. (ie portering, printer, stores etc.)
• Number of Times required to answer the phone at the nursing
station
• Time from call requesting bed until time the bed is ready for
patient. Including whether completed by bed control or unit
environmental services staff.
• The amount of time Clinical leader spends reviewing and
completing narcotic sheets
Measure
• Track the times of Physician arrival on the unit.
• Track the times the discharges are written, time patient left unit,
what service the patient was under.
• Track the time spent clarify orders
• Tracking the amount of time spent reporting shift to shift including
the hands off and reports between disciplines during the shift.
• Time spent updating report sheet
• Track the documentation on the admission history that populates
to the discharge summary
Analyze
There is an average time from physio consult to documentation of 22
hours; this is within the standard, but may be a gap for other health
care providers.
Overall ward clerks and nurses daily average of time spent off the unit
is not as much as previously reported however there is certainly
fluctuations related to demands on particular days that can limit patient
care hours.
Phone calls at the nurses station consistently show higher numbers of
calls from other nursing units as opposed to families which was
previously thought. Further data analysis might provide more insight
into the reason for other nursing units/supervisor calls.
Analyze
The bed control staff are completing the beds when requested taking an
average time of 51 minutes to complete. Housekeeping provided
additional support when isolation rooms were identified.
On average the clinical leader spends 5 minutes a day reviewing narcotic
sheets. Note that time fluctuates with her available time.
Physician arrival time on the unit occurs most often in the am with only a
few physicians arriving in the afternoon. Discharge order times do not
seem to be impacted as the majority of discharge orders are written early
in the day.
Overall, discharged patients left in a timely manner leaving 99 minutes
after discharge order was written.
Analyze
The amount of time clarifying physician orders was not noted to
consume much nursing time as previously thought.
The amount of time reporting seems to take up nurse patient hours with
the huddles from team members to team leaders taking the most time.
Updating the report sheet is another component (tool) of the report
process with not all team members using the tool which takes up both
nursing and ward clerk time. The service delivery (surgical services )
leads to more rapid turnover and therefore frequent updating.
The admissions are mainly completed by the floor staff as opposed to
float staff. Elements helpful for discharge planning on the admission
assessment and history form are not completed. The discharge
planning/education is poorly documented.
Improve
PDSA 1
Description: Following the physio assessment, Physio does an
orderable for nursing when applicable to communicate plan of
care. (ie. ambulation order).
• Following seeing the patient the physiotherapist will initial and
check the unit boards indicating the patient was assessed by PT.
Date Implemented: June 16th, 2014
Improve
PDSA 2
Description: Revise reporting process to do paper reports rather
than taped. The written report created will provide a concise
standardized process to communicate necessary patient
information for direct patient care from shift to shift, as well as
act as a working reference tool to replace the current report
sheet.
Date Implemented: June 16th, 2014
Improve
PDSA 3
Description: Assess and streamline documentation to ensure it
meets patients’ care needs.
• Physio and nursing will use the ongoing discharge planning form
to document the functional and home environment assessments.
Date Implemented: June 16, 2014
Improve
PDSA 4
Description: Improve the Documentation of Patient Teaching
Date Implemented: June 16th, 2014
Improve
Aim statements:
80% of patients will have documented teaching prior to
discharge.
Reduce overall reporting time for test team by 50% for 24 hours.
80% of functional and home environment assessments will have
more than two data elements documented within 24 hours of
admission.
90% of all patients will have ambulation orders (when
appropriate) entered by physio following assessment of patient.
Analyze% of ambulation orders placed when appropriate
Patients with Ambulation Orders
100%
88.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Pts with PT Consult % Pts with Ambulation Orders
% o
f P
ati
en
ts
Analyze
Report Times - Green Team
0:00
0:07
0:14
0:21
0:28
0:36
0:43
0:50
0:57
1:04
1:12
1 2 3 4 5 6 7 8 9
Avera
ge T
ime
T2Average T1 Average
1 Night RN report prep
2 Day Staff receiving report
3 Team members to Team leader
4 Clinical Leader to Team leaders
5 Evening Staff receiving report
6 Day RN report sheet prep
7 Night Staff receive report
8 Team members to Team leader (N)
9 Team leader to 2300 staff
T2 Average Total/Day = 3:15
Average report times for Green Team
Analyze
Report Times - Blue Team
0:00
0:07
0:14
0:21
0:28
0:36
0:43
0:50
0:57
1:04
1 2 3 4 5 6 7 8 9
Avera
ge T
ime
T2 Average T1 Average
1 Night RN report prep
2 Day Staff receiving report
3 Team members to Team leader
4 Clinical Leader to Team leaders
5 Evening Staff receiving report
6 Day RN report sheet prep
7 Night Staff receive report
8 Team members to Team leader (N)
9 Team leader to 2300 staff
T2 Average Total/Day = 3:35
Average report times for Blue Team
Analyze
Report Sheet Prep Times - Night RN
0:00
0:14
0:28
0:43
0:57
1:12
1:26
1:40
1:55
2:09
6/16
/201
4
6/17
/201
4
6/18
/201
4
6/19
/201
4
6/20
/201
4
6/21
/201
4
6/22
/201
4
6/23
/201
4
6/24
/201
4
6/25
/201
4
6/26
/201
4
6/27
/201
4
6/28
/201
4
6/29
/201
4
6/30
/201
4
Tim
e E
ach
Day
Night RN report prep - Green
Night RN report prep - Blue
Range Green = :30 - 2:00
Blue = :15 - 2:00
Report sheet prep times for Night RNs
Analyze
Report Sheet Prep Times - Day RN
0:00
0:28
0:57
1:26
1:55
2:24
2:52
6/16
/201
4
6/17
/201
4
6/18
/201
4
6/19
/201
4
6/20
/201
4
6/21
/201
4
6/22
/201
4
6/23
/201
4
6/24
/201
4
6/25
/201
4
6/26
/201
4
6/27
/201
4
6/28
/201
4
6/29
/201
4
6/30
/201
4
Tim
e E
ach
Day
Day RN report sheet prep - Green
Day RN report sheet prep - Blue
RangeGreen = :25 - 2:00
Blue = :10 - 2:25
Report sheet prep times for Day RNs
Analyze
Admission & Discharge Tasks
97%
60%
20%
11%
3%0%
93%
59%
86%
73%
28%24%
0%
20%
40%
60%
80%
100%D
isch
arg
e s
um
ma
ry
D/C
tea
chin
g/in
stru
ctio
ns
(da
y o
f D/C
)
Ho
me
en
viro
nm
en
t
Fu
nct
ion
al
ass
ess
me
nt
Pa
tien
t te
ach
ing
(pri
or
to D
/C)
D/C
pla
nn
ing
ass
ess
% o
f P
ati
en
ts
Time 1
Time 2
% Completion of Admission and Discharge tasks
Improve
Aim statement:
• 80% of patients will have documented teaching prior to
discharge.
28% of patients received teaching prior to discharge which was
an improvement from the previous measurement of 3%.
• Reduce overall reporting time for test team by 50% for 24 hours.
• Both teams tested written and bedside reporting. No
improvement in time lines as numerous issues being worked
through.
Aim statement:
• 80% of functional and home environment assessments will have
more than two data elements documented within 24 hours of
admission.
• 86% of the patients have a documented home environment
while 76% have a documented functional assessment.
• 90% of all patients will have ambulation orders (when
appropriate) entered by physio following assessment of patient.
• 89% of appropriate patients had ambulation orders.
Improve
ImproveStaff comments and customer feedback on the improvements
Ambulation orders from PT are valuable for nursing staff
Physio and other Allied Health staff value Discharge planning information; its also
useful for nursing on multidisciplinary rounds
Informal survey showed that patients and families feel positive about bedside
rounding; it helps them know the faces attached to the names on the bedside board
It is helpful to have both reports completed by 0800
Some staff struggled and gave negative feedback about the new reporting
format/process
Written reports are a fundamental change; it takes time to get used to such a big
change. Report completion is improving as staff become more familiar
Clinical lead values face-to-face time with patients
ControlWhat controls have we put in place to ensure that performance
does not lapse?
Icon taken off ‘downtime’ computer; staff will not be able to document
there in error (IT, Melissa)
Ambulation orders will become standard for appropriate patients
(Angela)
Duplicate or additional report sheets will be removed (Lisa, Melissa
and WCs)
Storage room has been organized, standardized and colour-coded to
reduce risk and save staff time (Lela/WCs, Cheryl)
Printer/fax machine is better placed for staff use and efficiency
ControlWhat controls have we put in place to ensure that performance
does not lapse?
Periodic chart audit of documentation (home environment, functional
assessment, patient teaching) (Lisa and Melissa)
Ongoing education, communication and demonstration to take place
around written report process; using emails, verbal and written
memos/posts (Melissa and SWAT team members)
Training and/or demonstration for nursing staff on how to conduct
bedside rounds; tip sheet is developed (Melissa)
Provide training on documentation and expectations for ward clerk
role (Lela, Pam)
Sustaining MeasuresWhat data should be looked at on an ongoing basis? (6 data points)
Physio
Ambulation orders (6 x once a month); snapshot of % of appropriate patients with
these (second Thu of month)
Documentation
Chart audits (3 x bi-weekly, 3 x monthly) of home assessment, functional
assessment and patient teaching); (second Thu of month)
Home environment/functional assessment require 2 data elements within 24 hrs
Ensure different teams are audited
Snapshot of all patients in surgery beds
Reporting
Measure report time (for one day-24 hours) x 6 months (second Thu of month)
Lessons LearnedWhat were some of the key things we learned about quality
improvement while doing this project?
Communication is challenging with 24/7 staff
Project and PDSA cycle timelines are tight/challenging; need to be attentive
and available to project needs
Unit leadership team collaborated and communicated well amongst each
other
Inclusion of other services (Physio and Environmental Services) was a benefit
to the team and the project
Good planning and communication to impacted services/areas around the
changes we are making is important (i.e. IT, Telecommunications, Materials
Management)
Identifying and addressing staff concerns is important
Spread PlanHow will we communicate and share our project?
The project is a standing agenda item at Nursing Advisory and Nurse Managers
meetings
Our sponsor/CAO continues to update at Medical staff meetings
Staff on Restorative unit are requesting written reporting and bedside rounds
(starting Monday!!)
ICU will be standardizing their Supply Room
ICU also propose beginning daily multi-disciplinary rounds (i.e. Pharmacy, PT,
RT, Nurse Supervisors), and moving to standardized written/verbal reporting
(away from taped report)
Physio will spread use of Ambulation Orders to all appropriate patients admitted
to PCH
Project team will attend Celebration Day
Next Steps
What is next QI project, next steps or next place the project is
spreading?
Train floats, nursing supervisors and new staff on the written report and rounding
processes
Collaborate with CIS in developing electronic reporting tool
Communicate with union around resolving staff concerns
Identify and resolve individual issues around written reporting process
Invite staff to a meeting/discussion
Move forward with getting rid of the kardex on Surgery unit
Present staff with alternate options for getting kardex information
Supply room will receive ongoing reorganization/improvement in collaboration with
Material Management