Critical Path Network

Multidisciplinary meetings lower LOS, excess days

Mandatory meetings involve all disciplines

Within 45 days after daily multidisciplinary patient care conferences were instituted at North Fulton Regional Hospital, the hospital's average length of stay dropped by more than a day and excess days decreased by more than 300 days within the first quarter of implementation.

The initiative has increased the hospital's compliance with core measures and allowed the case management department to better identify and track patients in observation status, says Kamela Sooknanan, RN, administrator of clinical quality improvement and case management services for the 202-bed hospital in Roswell, GA.

"The greatest asset to impacting quality of care has been the early identification of the need to involve additional disciplines in the patient's care and assigning accountability for meeting the patient's needs. All of the disciplines are there from the get-go to share information about the patients," she says.

Staff members make up for the time they spend attending the morning meetings later in the day because they don't have to track down individual disciplines for questions, Sooknanan adds.

When the hospital began the conferences in August 2006, Tenet Healthcare had begun a corporatewide initiative to have all the hospitals in the system implement daily patient care conferences to manage length of stay and improve overall patient outcomes.

"As case managers, we know how significant the multidisciplinary approach is to managing and coordinating patient care. In addition, at the time of the corporate roll out, our length of stay had been trending up. Therefore, this was the perfect opportunity to institute a daily care conference approach and meet both needs at once," Sooknanan says.

At the time, the hospital was holding weekly patient care conferences on the units, but they were poorly attended. The charge nurse presented the cases, and the team focused on the discharge plan and information sharing.

"The meeting structures were lacking in the care plan development process. Many people thought of them as being case management meetings and they just didn't attend," Sooknanan explains.

Now, the directors of every department make sure their staff attend the meetings, and directors also attend the meetings.

When the mandatory meetings were instituted, many staff members complained about the time commitment and competing priorities.

Hospital management created a policy for daily patient care conferences, and the management team continually showed its support for the conferences.

For several months before the conferences were implemented, the team conducted focused housewide education, putting up posters on all the nursing units and introducing the concept of nursing and ancillary staff meetings. All directors received weekly e-mail updates. One-on-one education was conducted with key physician groups, and newsletters were sent to the entire medical staff.

The support of the hospital's leadership team was instrumental in getting the meetings off the ground, Sooknanan says.

"We let everyone know that these meetings were necessary to improve quality of care and length of stay. The way we approached it is that nobody gets a pass for not coming to the meetings on any day. It's ingrained as part of our operations," says Ilona Wozniak, chief operating officer.

In the beginning, Wozniak or someone else from senior management attended the daily meetings.

"This reinforced the expectation that we would see all of the multidisciplinary team members and directors at the meetings. If someone wasn't present, we would follow up with his or her supervisor. Directors are kept informed, and they know that a team is committed to this project and that it is mandatory for everybody to participate," she says.

Disciplines attending the meeting include case management; nursing; hospitalists on the medical units; physical, occupational, and speech therapy; pharmacy; respiratory therapy; nutrition; unit directors; ancillary directors; and the director of case management.

The meetings are held in the mornings at staggered times so that no two units are meeting at the same time, allowing staff who cover multiple areas to participate. Each meeting covers 20-30 patients.

The team discusses every new admission on the morning after admission and discusses every patient with a length of stay of four days or longer.

"Each patient is discussed each day with the exception of Day 3 of their admission. Many patients are discharged on Day 3 of their hospital stay," Sooknanan says.

The meetings are very formal and have strict ground rules, which include no side conversations, and are redirected as needed to keep the focus on the patients and the issues affecting the progression of care.

The team is committed to starting and ending the meetings on time and limiting the time to 30 minutes, Sooknanan adds.

"Whenever a case is complex, we off-line it and the people most closely involved finish the conversation after the meeting," she says.

For instance, if a patient has significant social issues, instead of spending time at the meeting coming up with solutions, the case manager would consult with the other team members after the meeting.

The case managers lead the meeting. They introduce the patients and the diagnosis and turn it over to the nurse to present the patient's clinical status.

The team focuses on what is keeping the patient in the hospital and potential barriers to discharge. These include diagnosis and current status, home/ social situation, invasive devices, respiratory status, physical therapy and occupational therapy needs, diet and intake, wound care, and pertinent tests and procedures and tests that are pending.

(For more information, contact: Kamela Sooknanan, RN, administrator of clinical quality improvement and case management, North Fulton Regional Hospital, e-mail: Kamela.Sooknanan@tenethealth.com.)