Critical Path Network

Case managers take the lead in throughput initiatives

Hospital ranks high on satisfaction, timely care

At Sioux Valley Hospital USD Medical Center in Sioux Falls, SD, case managers often take the lead in developing ways to move patients safely and effectively through the continuum of care.

"Throughput is an issue that is addressed collectively in our organization. It doesn’t belong only to case management, the emergency department, or surgery, but having the case manager out there on the front line, developing a close relationship with the physicians and the bedside staff facilitates the ongoing process of ensuring that patients move through the hospital in a timely fashion," says Diana Berkland, RN, MS, CNS, vice president and chief nurse executive for the a 487-bed tertiary care hospital.

For the third consecutive year, J.D. Power & Associates recognized the hospital under its Distinguished Hospital Program for the hospital’s commitment to providing patients with an outstanding inpatient experience. The hospital exceeded national benchmarks for inpatient satisfaction and performed particularly well compared to the national study in providing care to patients with speed and efficiency.

How it’s done

The entire hospital focuses on throughput issues, and the case management staff have developed initiatives, using comparative data to identify issues, and then coming up with long-term solutions.

They look at length of stay and other indicators by case manager, by individual and group practice, by unit, and for the hospital as a whole and compare that to regional and national benchmarks.

"Length of stay, direct cost, average cost, severity of illness, laboratory, imaging, and pharmacy are all variables that we benchmark to other hospitals to identify opportunities for improvement," says Doreen Miller, APRN, BC, MS, CNS, director of geriatric services and case management.

The clinical outcomes of patients and safe passage through the organization are the driving factors for the initiatives.

For instance, the orthopedic unit and other hospital departments collaborated to create the Center for Joint Success, a process improvement project to move joint replacement patients more efficiently through the hospital.

The nursing unit, physicians, case managers, social workers, surgical services, pharmacy, therapists, and the hospital’s marketing department collaborated on the project.

"We had looked at our length of stay and realized that we had room for improvement," Miller says.

All of the disciplines were involved in planning and making changes. "By streamlining the service, we now have physicians working off a similar plan of care and an integrated pathway," Miller explains.

The pathway schedules surgery for joint replacement patients on specific days (Monday and Tuesday) to facilitate patient flow.

Patients who are in the Center for Joint Success program come to the hospital, along with their caregivers (or coaches), a month before surgery for an intense educational program by the interdisciplinary team, which includes the nurse case manager, social worker, pharmacist, physical therapist, and someone from surgical services.

The physical therapist teaches the patient and coach pre-surgery exercises to strengthen the patient’s muscles so he or she can recuperate more quickly.

"If a patient has to learn the post-op exercises right after surgery when he may not feel well, it’s much more difficult. We work on this with them before surgery so they’ll be prepared," Miller says.

The pharmacist reviews all their medications to identify any pre- or post-surgical issues and to communicate with the physician and team. The goal is to have the patient understand the medications prior to hospitalization.

The case managers and social workers address their discharge needs and any issues that might be barriers to recovery.

"We find out if they have a caregiver at home and if not, we work on that ahead of time instead of at the point of discharge. We find out where their bathroom is in connection with the rest of the house, how easily it is accessible, how many steps they have to climb, and any adjustments they may need to make in the home," Miller says.

The equipment is ordered, and any services the patients will need after discharge are all arranged before admission. If they need nursing care or therapy beyond the hospital, it can be arranged in advance.

"Once they’re here, they know what is happening and they can move through quickly," Miller says.

The average patient in the Center for Joint Success stays about three days.

Physician support

In addition to decreasing the lengths of stay, the project has improved utilization of beds and human resources as well as supplies for taking care of the patients, Berkland says.

"The patients love it. They come together for class as a group based on their week of surgery and meet each other prior to surgery. They see each other in the hospital, and can better participate in their care because they know what is going on," Miller adds.

The team started with the hospital’s own physician clinic and worked collaboratively with those doctors to create a plan of care that calls for similar patients having surgery on the same day of the week.

"We started small and brought in just three or four patients at a time. They like the process and are so happy they’re recommending our hospital to their friends," Miller says.

"The initiative has grown and now physicians are targeting those surgery days," she says.

The Center for Joint Success is designed for any patient with joint replacement surgery and is located on a nine-bed wing.

Patients whose surgery is not scheduled on Monday and Tuesday receive similar care but are not part of the center’s experience.

"One of the key concepts is that this is elective surgery and the patients have time to prepare. If they come in well prepared and have done strength training on their alternative leg, it makes a huge difference. We look at it as investing the patient as a partner in the success of his care," Miller says.

The case management staff operate on a triad model with a nurse case manager, social worker, and utilization management analyst. Case managers all have a clinical specialty and work within a geographic location. Depending on the needs of the patient, they may follow the patient if they are moved to another unit.

They work closely with the physicians to manage patient care in real-time and ensure that patients move through the continuum of care on a timely basis.

The hospital publishes a daily bed briefing that is e-mailed to key stakeholders. It contains information about scheduled admissions, discharges, surgical patients who need to be placed, and the hospital’s staffing capability for that day.

The case managers on each unit contribute information each day about patients who are scheduled for discharge.

"The case managers design their workflow based on the unit needs, and the clinical care coordinators are doing the same thing right alongside of them," Miller says.

For instance, if a patient on the surgical unit has met the discharge criteria the surgeon established, either the case manager or the clinical care coordinator discusses it with the surgeon and facilitates discharge orders.

"The case manager isn’t the only one who is responsible for working with the surgeon. We have a real-time concept of managing patient throughput. The case managers and the clinical care coordinators work together to see that whatever needs to happen gets done," Miller says.

Moving patients efficiently through the hospital not only saves money, but it’s also what’s best for the patient, Berkland says.

Everybody in the hospital, starting with the emergency department and including each nursing unit, is responsible for ensuring that the patient moves through the hospital as efficiently as possible.

"It’s not that anyone is pushing the patients out. Everyone is helping pull them through. Whether it’s in the operating room or the emergency room, we strive to work in that direction. All of nursing is on the same page and all are working toward the same end, moving the patient through in a timely manner, meeting their needs, and making good use of their time and resources," Berkland says.

Case managers are the drivers of the interdisciplinary team and work with the physicians on the medical plan of care. Each nursing unit handles things a little differently because of the different needs of its patient populations.

The team on each unit has a daily huddle that includes the case manager, social worker, utilization management analyst, the clinical care coordinator, bedside nurses, and other team members when appropriate.

They make a quick review of patient needs for that day and discuss any new developments or changes in the plan for the day.

"The team members who need to know what is going on for the day attend. This is not the nursing unit report. It’s a meeting of key decision makers and people who carry out the plan of care," Miller says.

Interdisciplinary team meetings

Each unit also has a more formal and lengthy interdisciplinary team meeting in which individual patient’s plan of care are discussed.

The interdisciplinary team meeting is a more comprehensive review of patient care and patient needs. It’s scheduled routinely and as needed on each unit so the team can discuss the patients who have the highest priority. Physicians may attend the meetings if needed, and the meeting can be scheduled around the physician’s time.

Another interdisciplinary team meeting takes place each day for the subset of patients seen by the hospitalist service.

At Sioux Valley Hospital USD Medical Center, the case managers operate in a differentiated nursing practice with a shared governance model. The hospital achieved nursing magnet status two years ago.

The differentiated practice model for nursing includes the nurse case managers, the clinical care coordinators who manage activity on the unit and handle some daily staffing duties, advanced practice nurses with master’s degrees, and bedside nurses.

Under the hospital’s shared governance structure, each nursing unit elects a "senator" who attends monthly meetings where decisions are made about nursing practices at the hospital.

The hospital uses integrated clinical pathways and order sets grounded in evidence-based practice.