The process improvement project started the way many begin: The surgery center received comments from patients who said they wanted better discharge instructions.

“Patients would go into recovery and not remember things, so we started with a process improvement workshop for discharge instructions,” says Sandy Keating, RN, clinical director, Surgery Center San Carlos in San Carlos, CA, which is affiliated with Sutter Health’s Palo Alto Medical Foundation. “Once patients are medicated, coming out of surgery, they don’t remember talking with physicians. We call them the next day, and they might say, ‘I wish I could have talked to the doctor,’ and we say, ‘You did talk to the doctor.’”

Surgery center staff decided to give patients a laminated sheet with discharge and recovery instructions. It includes illustrations, and the language is written at a third-grade reading level. “It also is translated into Chinese and Spanish for our population,” Keating notes.

Patients see the laminated copy at the surgery center, and they can take home their own unlaminated copy. The instructions include six panels on both the front and back. (Editor’s Note: See sidebar at the end of this article for more about the instructions.)

The surgery center also targeted same-day cancellations for a process improvement project. “At San Carlos, we have a binder where we document what the cancellations are and the reasons for them,” Keating says. “We call people to get more details so that we have information on core issues.”

The process improvement committee for the Palo Alto Medical Foundation’s six centers focused on this project, tracking surgical and other reasons for cancellations. They started with gastrointestinal (GI) patients, but are expanding to all patients because of such excellent results, Keating reports.

“We created 12 categories of cancellations with standard code inputs, and we are building these into the online program, where we document the cancellation,” she explains. “We started calling patients when someone was a no-show, and we would find out the reason. For instance, we found a patient who had a high deductible and couldn’t afford to pay for the GI prep solution.”

Another patient spoke only Spanish, and did not know to take the prep product because the patient did not see the Spanish instructions. Without calling those patients, they would only have known the patients were no-shows, Keating says.

“There’s always more to the story than just a no-show,” he observes. Poor preparation might lead to a patient not following the dietary instructions and being unable to tolerate the prep solution, Keating notes. “They were supposed to change their diet a week ahead, and some didn’t read the instructions until the day before,” she explains. “Now, we call them a week before the procedure, and send out instructions on My Health.”

A quality improvement committee, which meets monthly, identified this as a project that everyone could work on. The surgery team identified what the preparation issues were, and came up with solutions that could be implemented in that surgery center and other ones connected with the healthcare organization.

For example, patients needed clear and simple preoperation instructions. Previously, these instructions were confusing and too long. Some patients were not reading all the way through or did not understand what they were reading. Thus, patients did not complete every task before surgery. “We cut instructions from seven pages to two pages,” says Jannette Gray, RN, BSN, periop manager, Surgery Center San Carlos. “The instructions’ first five bullet points are the most important information for the patient’s procedure. We go [into] further details as someone goes through the document.”

Not only were instructions lengthy and confusing, another issue was too many types of instructions: online instructions, instructions for medication, and the clinic’s lengthy instructions. Patients would report that they read the instructions, but then they would misplace them. That would lead patients to read other (possibly incorrect or misleading) sources of information the day before the procedure. “We worked with our GI doctor to decrease the instructions,” Keating says.

Now, there is one instruction sheet, used at all of the system’s surgery centers. “Everything you need for that procedure is on one page and the back of it,” Gray says. The center also improved its preoperation calls, standardizing and streamlining that process. “We were calling patients seven days ahead and, then, calling one day ahead,” Gray says. “But we were missing people in the middle of the week. We changed it to a seven-day call, and then a three-days-out call.”

The revised instructions included checkboxes with quick visual cues. For example, one box says the patient should call the center if there are any problems. If patients report problems during the call three days before the procedure, then the procedure can be cancelled and rescheduled, reducing the likelihood of a same-day cancellation, Gray explains. “The day before the procedure, it’s too late,” she notes.

The project worked well, reducing same-day cancellations. “The four surgery centers that have GI procedures did the project,” Keating says. “At one center, the number of same-day cancellations dropped from 6.4% to 2.9% after the improvement.”

In sum, before revising the instructions, there were almost four in 10 same-day cancellations because of poor preparation. After piloting the changes, this improved by 70%, Keating reports.

Discharge and Recovery Instructions

After many patient complaints, staff at the San Carlos Surgery Center decided to provide patients with a sheet that includes specific discharge and recovery instructions. One side includes instructions related to surgical discharge and recovery:

Pain Management

- Take over-the-counter or prescription medications as directed by your doctor;

- Apply ice or heat, if instructed.

Diet Today

- No alcohol for at least 24 hours;

- Start with a light meal to help prevent nausea and vomiting;

- Stay hydrated and drink fluids.

Call Your Doctor

- Signs of infection;

- Heavy bleeding;

- Ongoing nausea or vomiting.

Wound Care

- Keep surgical dressing clean;

- Follow specific wound care instructions given in recovery;

- Monitor for possible signs of infection (fever 101° F or higher, swelling, heat, drainage, or redness).

The other side of the sheet includes instructions for colonoscopy/endoscopy discharge and recovery:

What is Normal

- Endoscopy: mild sore throat and/or abdominal bloating for one to two days;

- Colonoscopy: cramping or bloating;

- Pass gas to help with bloating and take Tylenol for pain, if needed.

After Today

- Expect a follow-up call from the surgery center on the next business day;

- Biopsy/polyp results will be communicated via phone, mail, or My Health Online within 14 days.