Ways a hospital can improve DP process

Communication gap should be tackled

While hospitalists can provide consistency in the care of hospitalized patients, there can be drawbacks when it comes to transitions in care.

At least one hospital has tackled this issue as part of a quality improvement project, initiated partly through Project BOOST.

"We recognize that from the hospitalist perspective, we have taken over more and more of inpatient care of patients," says Christina McQuiston, MBCHB, clinical director of senior services and a hospitalist at Asheville Hospitalist Group and medical director, senior services and Project BOOST team co-leader at Mission Hospital in Asheville, NC.

"There's a communication/information gap that did not exist in the past, when primary care physicians provided care continuity from inpatient to outpatient," McQuiston says. "In the past, the PCP took care of patients in the hospital, knew what had happened to them, and continued to see them when they left the hospital."

This is no longer the case.

"Our hospitalist group has done a very good job of coordinating with the hospital and getting paperwork to physicians in a prompt manner when patients leave the hospital, but we were not doing such a good job of making sure patients go to see their PCPs at discharge," McQuiston explains. "We know that was not happening in other areas of the hospital, from general surgery to orthopedics, and we knew there were more gaps in care transition."

Hospital leaders identified two major issues that needed to be addressed to improve the transition of care process: First, the discharge planning, case management, and social work areas in the hospital were decentralized and had no standard practices, and, secondly, there were problems with communication during care transition, she says.

McQuiston first focused primarily on the communication hand-off piece, she says.

"It was only once we got into the weeds with this that we realized our discharge process was broken, and we saw this as an opportunity to deal with that issue," she explains. "We couldn't deal with Project BOOST until we dealt with that issue."

As hospital leaders recognized the problem and determined to improve the discharge process, they hired a case manager leader who became an integral part of the Project BOOST team.

"She's been able to pull our case managers and discharge planners together around the BOOST project, and they're taking a key role in this," McQuiston says.

So far, the changes are new, but there likely will be some outcomes based on 30-day readmission rates and patient satisfaction scores available by this summer.

Here are some of the steps the hospital has taken to improve its discharge process and care transition:

• It uses a computerized discharge process. The computerized discharge process involves a discharge piece called DEPART, which is a work in progress, McQuiston says.

"It's an interactive discharge record that all disciplines can enter information into, and everyone can look at the record," she explains. "Also, there's a medication reconciliation piece."

The information entered in the system includes information from nursing, occupational therapy, physical therapy, case management, nutrition/dietary, and physicians.

• DP begins on the day of admission. "What happens now is, the case manager has variable lengths of notification time from a couple of hours to several days, and that's one of the problems we're trying to address with BOOST," McQuiston says.

"We're starting the discharge process on admission, and we're introducing daily, multidisciplinary rounds," she says.

The core group participating in rounds includes a pharmacist, nurse, case manager, and physician, but anyone else can participate as needed, she adds.

"The purpose is to give much more warning to case managers and discharge planners, so they can address all the necessary issues prior to discharge," McQuiston says. "There are several pieces, and one is to identify patients who are likely to have problems at discharge or gaps in their care."

The goal is to start addressing these issues as soon after admission as possible.

For instance, one issue the hospital has addressed involves the patient's mobility in the hospital and at home, including patients' risk for falling and home safety issues, McQuiston says. Other issues discussed are patients' social support resources, need for durable medical equipment, and financial issues.

"Everyone who has something to contribute talks about these," she says. "If an RN knows something the PT doesn't know, then this can be communicated in the multidisciplinary rounds."

The goal is to provide staff with a format for this type of communication that is more immediate than having people write chart notes that might never be reviewed, she adds.

This method hopefully will bypass the silos in which each discipline does its own thing with too little interdisciplinary communication.

"We try to keep it efficient and complete the rounds in a timely manner," McQuiston says.

• It sets goals and obtains buy-in. "We elected to start this project as a pilot program with the express desire that this will be the model for how we do discharge planning and transitions across the hospital," McQuiston says. "We hope by piloting this to address barriers, because sometimes you don't know what your obstacles are."

The pilot project has obtained buy-in from staff and leaders, partly through having a nursing case manager champion the project, she adds.

Before the hospital hired a new nursing case manager, discharge planning leaders stressed to the hospital administration that it was important to have this new person involved very quickly with the discharge quality improvement project, McQuiston notes.

"So, the new nursing case manager was very supportive of all the goals of BOOST and felt she could be an advocate for the BOOST project with case managers and discharge planners on a hospital-wide basis," she explains.

"At that point, we had not decided who was going to be doing the follow-up calls, whether it'd be nursing or unit secretaries or physicians," she says. "But the new manager wanted this to be a case management piece, and she obtained buy-in on the unit for this plan."

It's been more challenging to obtain physician buy-in on the discharge planning changes, and work continues on this front, McQuiston says.

"The hospitalists I work with feel they do their piece fairly and conscientiously," she adds. "But they're often unaware of exactly what goes into making a good discharge and a good transition."

Another point is that no one wants to see his or her own workload increase.

"We've tried to sell this as a process that will not make more work for staff, but which will change the way we do things to make the process more efficient and effective," McQuiston says.

"If this is going to be successful, we cannot add another layer of bureaucracy or work," she says. "If we're going to put in something new in the process, then we'll have to take something else away, so it's really a re-engineering process."

• It piloted changes. Mission Hospital started a pilot project on the medical unit and has planned to add a pilot on the surgical unit, because the challenges are different, McQuiston says.

"Once we have worked out the kinks of what works and what doesn't, then we'll be ready to look at taking this hospitalwide," she says.

"What has happened is that as other units in the hospital have gotten wind of what we're doing, they've been eager to incorporate some things we're doing, and that's naturally coming about without us having to set a timeline or deadline to it," McQuiston says.

For example, the cardiovascular services have attended some meetings and have looked at making some changes based on the discharge improvements discussed there, she adds.

"We'll make all of our materials available for everyone," McQuiston says.