Transitions of Care
20,000 Days Campaign Learning Session 3
11-12 March 2013
Clinical Lead:
Martin Chadwick
Team members:
Dr Ajay Kumar, Annelize de Wet, Dr Beven Telfer, Brian Gabolinscy, Dr Carl Eagleton, Carolyn Kemp,
Catherine Simpson, Chee-Khiang Sng, Clivena Ngatai, Diana Dowdle, Dot McKeen, Erin Currie,
Fionna Winter, Fran Birt, Galumaninoa Tasi-Perez, Gregory Winkelmann, Helen Thomas, Ian KaiheWetting, Janene Lawrence, Dr Jeff Garrett, Jo Goodfellow (GAIHN); Karla Rika-Heke, Maika
Veikune, Marie Chester, Michele Carsons, Moana Houia-Poka, Penny Wilkings, Ruth Prakash,
Sanjoy Nand, Sarah McMullen-Roach, Simon Kerr, Jessica Ryan, Deanna Williams (POAC)
20,000 Days Campaign Project Support:
Prem Kumar (Improvement Advisor)
Monique Davies (Project Manager)
Refining Our Aim
Transitions of Care was a very large collaborative with an even larger brief of improving the inpatient
hospital journey and reducing unnecessary delays to discharge.
Our original aim:
By 01 July 2013, we will improve the MMH inpatient journey from admission to discharge by
utilizing a goal date for discharge and looking to reduce the average length of stay by 0.2 bed
days within medical and surgical inpatient services. To assist in reaching this goal we will look to
facilitate earlier notification of referrals to appropriate inpatient services and diagnostics, nurse led
discharges and weekend discharges. We will also work on our transition of care processes with
the patient’s primary healthcare provider.
By focussing our improvement work on two work streams: the patient's Goal Discharge date (GDD)
and improving the volume of Weekend Discharges we have accomplished a firm direction for testing
our improvement ideas.
The following two slides show our PDSA progress…..
Transition of Care
Primary Drivers
Secondary Drivers
Tertiary Drivers
Change Concepts
Driver Diagram-v5
Admission Process
Date: 4 July 2012
Discharge
decision making
Advance Planning
MDT availability
Ward round
Timely decision
making
Specific Change Ideas
(PDSA tests)
×GDD for each patient X
×Rapid ward rounds
Care pathway
STAAR
Discharge
documentation
Discharge
planning
Timeliness of
documentation
Quality of
documentation
Simplify
Standardisation
Shared care plan
PT self mgmt
Pt involvement
Pt Education
Family
communication to
family
To improve
the admission
to discharge
process of
Middlemore
Hospital
inpatients by
01 July 2013
Discharge checklist in ward X
Ticket for Discharge
Communication
Communication to
Primary/Res. care
Prevention
(Rapid Response)
Post Disch phone call
Patient awareness on EDD
Discharge
communication
Coordination
Advice family on EDD
Verbal handover
Effective handover
Treatment
Measures:
1. LOS
2. Readmission
3. Pt Experience
Measures:
1. ALOS
2. Readmission
3. Pt Experience
Measures:
1. LOS
2. Readmission
3. # of Pt discharged
Weekend
discharge
St John ordering
process
Transfers
Improve transport
delay
CMDHB to own and have equipment
POAC
Correct Prediction of equipment
Std wknd plan-Dx info in one
place with reasons
Discharge
/Transition lounge
Access to
Diagnostics
Discharge
clinical decision
making
community
resources
Bloods
Patient held care plan (Passport)
Availability of
Consultant
?
MDT Access
Accessibility
Availability
Home+
community
services
Use A2D planner for Dx
Self Dx
X-Ray, U/S, CT
Access to
Diagnostics
Stoking of equipment
Share team contact with
pt for Dx follow up
Pt booked in for GP post Dx
Weekend rounding
Pilot nurse led discharge
Pt to have Dx date & time
Increase the use of POAC
7 day staffing
Combined EDS for all service (MDT led Dx)
Formal process for Pt review-Task Mgr
Transition of Care
Nurse setting
the GDD
Pt awareness
on GDD
PDSA Tree
Date: 27/11/2012
Reviewed 27/02/2013
Who, How, When?
Establish GDD &
Daily Review
To have a standardised
process to provide each
patient with a GDD
How and what is the best
way to establish a GDD?
Staff awareness
on GDD
GDD match with
actual Dx date
GDD in MDT
meeting
# of clinical
directors believe in
establishing GDD
Goal Discharge Date
Pt less than 48 hour
Cultural Support to inform
– Maika/Ian 23/12
Patient &
Family
Drs
To have a
standardised
process to share
GDD
Best way to
communicate the
GDD to patient and
interested parties?
PDSA Summary Tree
Nurse to inform PtRuth
DOC to use care plan for
updated GDD info
Process Map
Janene/Michele 23/1
CAT tool
usefulness
Post ward round delay in
services for Pt > 7 days
Sharing
GDD
7
Is the GDD documented
on care plan?
GDD mentioned in
notes
CAT tool to indentify
why Pt waiting
Active
PDSA
GDD by Doc post acute
ward round – Brian 17/12
Check consultant
aware of GDD in mind
GDD in ward 33
Janene & Michele 23/1
Reasons of Pt
waiting on Bed
Goal
Discharge
Date
Reason of GDD not metRuth& Michele 12/12
Doc to use care plan to review
GDD-Ruth/Michele 5/12
Pt awareness on
GDD-Surgical
GDD given to surgical pt and
any plans documented
Aim: To improve
the number of
inpatients having
GDD from 0% to
100% also
To increase the
number of
inpatients
achieving the GDD
for from 0% to
100% by July
2013.
Staff to set a GDD based on
the top 10 DRGs-Michele 5/12
Doc reviewing /confirming
GDD-Ajay 5/12
Update GDD on white board
Staff
Update GDD on WiMS
Other
Services
Ascertain ref
process in ward 6
E-referral –
Erin 5/12
PDSA box
Timely task referral
Prediction:
GDD will
improve the
patient
experience and
efficiency. Also
this will reduce
the LoS
Achieving the
GDD
To have the
processes in
place to achieve
the GDD
How can we
achieve the GDD
as a team
Repeat PDSA
What ref system are
available in service dir.
Active PDSA
Identifying Pt need @
admission in EC
(Ajay Kumar/ Fionna W)
Identifying Pt need @
admission in EC 4 pts
(Ajay Kumar/ Fionna W) 13/1
Repeat with
interventions
Adopt
Early Dx if Pr referred
to NASC earlier
Adapt
Delay in x-fer to rehab
Abandon
Referral system assessment &
documentation from acute to AT&R
Discharge to HHC
Known patient dx
communication to HHC
HHC to receive
Dx list twice
daily
What's
Happening
Owner: Prem Kumar
Transition of Care
Call On Call Dr to
clear the delay in
Dx for non medical
reasons –Fionna
13/12
PDSA Tree
Date: 27/02/2013
How many
didn’t meet
criteria & why?
Fionna 5/12
Who, How, When?
Nurse
Facilitated Dx
Identify the
criteria for
Dx
Process
Mapping
Identify the Dx
patient on
Friday –
Fionna 5/12
Measures:
No of NFDx
Criteria Led
Dx
Weekend
Discharge
Aim: By 01 July
2013, we will
increase by 20%
the number of
Middlemore
Hospital medical
and surgical
inpatients
discharged on
Saturdays and
Sundays.
Increase
referral to
POAC
How many
weekend
reviews
No of referrals
All patients
have
weekend
plan
All Pt have
weekend
plan
To identify pt with
no clear plan and
require a non
medical input –
Fionna 5/12
1.Clarity on why
they waiting on
weekend
2.Why not clear
Measures:
Measures:
No of weekend Dx
Readmission rate
Using task
manager for
NFD referral –
Fionna 13/02
Weekend Discharge
PDSA Summary Tree
Ward 2
identification of
pt for POAC
Brian/Fiona
Measures:
9
Using task
manager for
medical
review-Brian
13/2
Causes of less
ref-Clivena 20/2
Knowledge &
understanding
Active PDSA
Test Ward 2 template for
weekend plan-Sarah
Test the template
in medical wardFionna 13/2
Weekend plan are
clear
3 Day Dx for
weekend (OT)
Identify delay in
Dx (OT) -Sarah
Delay due
to IV
Pt Transfer
No Time Barriers to
Dx to RH – David
Lange RH
Identify the reasons for delay
with Radiology -Beven 20/02
Transfer
to AT&R
Fit for Dx but
delay due to rest
home 30/01
Chart review to
ascertain
reason for
delay for PICC
Rest home baseline
Penny/Prem
Reasons for delay in tfr to rest
home on 10 pt-Fionna 27/02
PDSA box
Active PDSA
Adopt
Adapt
Abandon
What's
Happening
Goal Discharge Date
Change Packages Examples
Secondary Drivers
Change Concepts and Ideas for PDSA Testing
Establishing a GDD for
each patient in Ward 6
Methods of establishing GDD trialed
nurse setting GDD on admission
GDD following medical ward round
Set at daily MDT meeting (Mon-Fri only)
GDD set and recorded consistently (recorded on run chart weekly)
Recorded on ward whiteboard, WiMS reports and ward round book
Accuracy of GDD
Review actual discharge date with GDD (recorded on run chart weekly)
Review of GDD
Reviewed on ward rounds and at 8.00am MDT meeting (Mon-Fri only)
Establishing a GDD for each patient in Wards 2 and 33N (Start date: January 2013)
Weekly data collection per ward of GDD consistency and accuracy
Following review of data from three wards there is a higher degree of consistency noted in
ward 33N’s process, i.e. there is no differentiation in results between weekdays and
weekends.
Process map to look at how GDD is established and reviewed in each ward with a view to
standardization of process
Accuracy of GDD
PDSA on 3 wards, 5 patients each and recording reasons for a change in GDD
ALOS per DRG Setting GDD
oPDSA on 5 patients on ward 6 having a GDD using the DRG ALOS chart.
October 2012: Start date
February 2013: Rollout to
Wards 2 and 33N
Goal Discharge Date
Change Packages Examples…cont
Secondary Drivers
Change Concepts and Ideas for PDSA Testing
Sharing the GDD
To facilitate ongoing communication about discharge-related issues
between patients/ families, ward staff and allied health services.
 Patients advised on ward rounds of likely GDD
 Ensure that all staff are aware and working toward the agreed GDD
 Audit on wards to review patient knowledge of the GDD
 Maori whanau support worker to ensure their patients (from IPO5 lists) on
wards 6, 2 and 33N are aware of their GDD
 Repeat PDSA with Pacific cultural support teams
Achieving the GDD
The aim is to promote patient satisfaction and encourage timely discharges
by ensuring that everyone is expecting and prepared for discharge.
 Knowledge of a patient’s GDD prompts allied health and ward staff to
discuss what else needs to be done to meet the goal discharge date.
 6 week PDSA in ward 10 (weekend discharge group) looked at reason for
delay to discharge. Data to be reviewed and PDSAs to look at resolving
specific delay issues
 Discharge to Home Healthcare (PREM TO ADD)
Weekend Discharge
Change Package Examples
Secondary Drivers
Change Concepts and Ideas for PDSA Testing
Increased referrals to
POAC
Establish baseline data for current volumes of POAC referrals from Middlemore Hospital
(assisting early discharge for patients)
Collecting data on why surgical staff are not using the POAC service (if beds available on the
ward staff perception no need to POAC)
Increasing awareness of POAC services to nursing and medical staff
Criteria Led Discharge

Decrease LOS

Morning discharges
possible!

Increase in weekend
discharges

Improved quality of
discharge planning

Increased patient and
staff satisfaction
New inter-collaborative group to be formed “SMOOTH Transitions”
Weekend plans for Patients
All patients to have a weekend plan
Identify patients with no clear weekend plan, discuss with team
6 week PDSA in ward 10 (weekend discharge group) looked at reason for delay to discharge.
Trialing use of weekend plan template (used in ward 2) in one of our PDSA wards with a
view to reducing delays
A generic format to be developed and PDSA tested in a test ward
Weekend Discharge
Change Package Examples…cont
Secondary Drivers
Change Concepts and Ideas for PDSA Testing
Nurse Facilitated
Discharge (NFD
established in medicine:
looking to better
utilisation rates)
Considerably fewer discharges take place over the weekend compared to weekdays.
The provision of a weekend nurse facilitated discharge process assists to increase
discharge volumes on weekends when medical staffing numbers are reduced.
Increase the number of NFD discharges on weekends by:
•
•
•
•
•
•
Criteria for discharge by NFD established and shared with staff
Increase knowledge of NFD weekend service with medical teams. PDSA testing
with one team not currently utilising the NFD service to see if increased
awareness results in increased referrals to NFD
Review patients referred to NFD for discharge on Saturday and criteria not met,
record reasons why? Look at referring to medical team to review on Sunday to
see if fit for discharge to increase rate of successful discharges vs NFD referrals
NFD team to identify and accept referrals for patients appropriate for NFD over
the weekend on Friday afternoons
Use the 10 day list (i.e. patients with current LOS in hospital > 10 days) and
review reasons for length of stay and facilitate access to discharge where
appropriate
Investigate via PDSA use of task manager for NFD referrals
Most Successful PDSA Cycles?
One of our most successful test of change was around the communication of
GDD to staff and other services.
Change Idea:
to communicate the GDD to the multidisciplinary team by
pitting the GDD on the WiMS sheet
Learning/Outcomes:
updating of GDD in WiMS assisted the information about the
patient’s GDD to be readily available to all staff involved in
that patient’s care at any time
Version: 1.0
Dated: 20/02/2013
Tests performed with unequal sample sizes
Month/Year
Jan12
Jan
F eb
M ar
A pr
M ay
Jun
Jul
M onth ( 2 0 1 2 )
A ug
S ep
O ct
N ov
20
10
__
M R=10.45
0
LC L=0
D ec
Jul12
30
45
Jun09
Nov12
Dec12
Jan13
Feb13
U C L=34.16
Jul07
Sep12
UCL=26.24
6
Jan12
EHB Ph 2-Gastro, 35N
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Jan12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jul08
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Jan12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Jan08
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Jan12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Jul08
May08
Mar08
5
May12
LC L=10.61
Mar12
D ec
Jul11
N ov
30
Nov11
O ct
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Jan12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Jul08
May08
Mar08
Jan08
Nov07
Sep07
Jul07
Jul 2013
Apr 2013
Jan 2013
Oct 2012
Jul 2012
Apr 2012
Jan 2012
Sample StDev
Jul07
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Jan12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Jul08
May08
Mar08
Jan08
Nov07
Sep07
Average Daily Discharge
90
Sep11
S ep
2
Jan11
A ug
EHB Ph1-Wrd 33,34
May11
Jun
Jul
M onth ( 2 0 1 2 )
Jan08
50
Mar11
M ay
Jun09
Jul10
A pr
EHB Ph1-Wrd 33,34
Nov10
M ar
EHB Ph1-Wrd 33,34
Sep10
F eb
3
Jan09
40
Jul08
20
Jul07
Nov08
Month/Year
Jan10
LCL=2.68
_
X=38.42
EHB Ph1-Wrd 33,34
May10
10
Jan
CL
Mar10
_
S=14.46
60
80
Nov09
20
U C L=66.22
10
Sep09
0
5
Total Number of POAC per month from MMH
Sep08
Tests performed with unequal sample sizes
May08
LCL=7.84
Mar08
1
Jan08
10
May08
_
S=15.37
Jul07
Jul09
Month/Year
40
Mar08
1
May09
LCL=37.37
40
Jul07
Jul07
Mar09
30
Transition of Care
February 2013 Dashboard
Nov07
UCL=114.83
Sep07
EHB Ph 2-Gastro, 35N
Jan09
2 2 2
Jul07
_
_
X=104.39
Sample Mean
Average Weekday Discharges (Med & Surg only)
Jul08
45
3%
Jul07
Nov08
_
_
X=53.26
Jul07
Sep08
UCL=69.15
LCL
Jan08
EHB Ph 2-Gastro, 35N
Jul 2011
3.40
May08
60
4
MMH
Mar08
Average Weekend Discharges (Med & Surg only)
40
Nov07
15
4%
Sep07
1
5%
Jul07
1
UCL
Nov07
Month/Year
6%
Sep07
2 2 2
Oct 2011
UCL
Jul07
90
LCL=93.94
Apr 2011
4.80
Nov07
100
Jan 2011
7%
Sep07
110
Jul 2010
LCL
Oct 2010
3.60
Apr 2010
3.80
Jan 2010
CL
Jul 2009
4.00
Readmission Rate
5.00
Oct 2009
4.20
Sample Range
5 5
Jul 2013
Apr 2013
Jan 2013
Readmission rate
No fo Discharge
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Jul 2012
Oct 2012
4.40
T otal number of Refer r al to P O A C
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Jan12
Mar12
Apr 2012
Jan 2012
Oct 2011
Jul 2011
Apr 2011
MMH
Sample Range
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Jan12
Mar12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Jan 2011
Oct 2010
Jul 2010
Apr 2010
Jan 2010
4.60
M oving Range
Jan12
Mar12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
EHB Ph 2-Gastro, 35N
Nov12
Dec12
Jan13
Feb13
Sep12
Jul12
May12
Mar12
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
Jul10
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Jul08
May08
Jul 2009
Oct 2009
ALOS
Average Length of Stay
Nov11
Sep11
Jul11
May11
Mar11
Jan11
Nov10
Sep10
EHB Ph1-Wrd 33,34
Jul10
EHB Ph1-Wrd 33,34
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
EHB Ph1-Wrd 33,34
Jul10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jan09
Nov08
Sep08
Mar08
EHB Ph1-Wrd 33,34
May10
Mar10
Jan10
Nov09
Sep09
Jul09
May09
Mar09
Jul07
Jul08
May08
Mar08
20
Jan09
2
Nov08
Jul07
Sep08
Jul07
Jul08
May08
2
Sep08
Mar08
Jan08
Nov07
Sep07
No of Discharge
Jul07
Jul08
Jan08
Nov07
Sep07
Jul07
80
May08
Mar08
Jan08
Nov07
Sep07
Jul07
Sample StDev
25
Jan08
Nov07
Jul07
Number of Discharge
75
Sep07
Jul07
Sample StDev
Measures Summary
105
Average Daily Discharges by Month (Med & Surg only)
EHB Ph 2-Gastro, 35N
7
UCL=105.68
7
_
_
X=89.77
75
60
2
LCL=73.85
Month/Year
EHB Ph 2-Gastro, 35N
UCL=39.23
30
2
2
40
5
Month/Year
UCL=22.90
20
0
5
5
MonthYear
1
15
0
1
_
S=27.82
20
LCL=16.41
Tests performed with unequal sample sizes
Month/Year
Average Discharges on Sunday (Med & Surg only)
EHB Ph 2-Gastro, 35N
UCL=52.97
_
_
X=41.38
20
LCL=29.79
May10
2
30
UCL=36.30
2
_
R=15.91
Month/Year
LCL=0
Tests performed with unequal sample sizes
Average Discharges on Saturday (Med & Surg only)
EHB Ph 2-Gastro, 35N
UCL=77.76
60
_
_
X=65.14
1
2
LCL=52.52
May10
3
30
UCL=39.51
_
R=17.32
Month/Year
LCL=0
Tests performed with unequal sample sizes
Contacts Clinical Leader: Martin Chadwick
Project Manager: Alison Howitt
Improvement Advisor: Prem Kumar
Highlights
Direction and Purpose
The group now have clarity of direction by the focus on two work stream areas: Goal Discharge Date
and Weekend Discharge
PDSA tests are completed, recorded and discussed at weekly meetings
The IHI PDSA Methodology is now well embedded and learning is gained from each PDSA cycle, in
some instances we learn more from our ‘failures’ than our successes
Working with the David Lange Rest home on our current PDSA “No Time Barriers To Discharge to a
Rest Home” has highlighted the willingness and generosity of primary care and community
organizations to be part of our improvement journey
Strengthening of relationships between services and professions has been a highlight of working
within this group
Achievements to date
-
The group have established and bedded in the process for setting a goal
discharge date in ward 6 and have worked to look at rolling out to wards
33N and 2. Data on the accuracy and consistency of recording of the GDD
is collected and presented weekly
-
The effect of a ‘published’ GDD for patients on these wards has a marked
beneficial impact on other staff in the planning and provision of allied
support services
-
Measurements established to look at the volume of weekend discharges,
referrals for discharge to the Nurse Facilitated Discharge team on
weekends and POAC assisted discharges