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Hospital projects focus on patient throughput
CM redesign among initiatives
A series of initiatives at Central DuPage Hospital has helped decrease length of stay and improve patient flow, according to Corinne Haviley, RN, MS, associate chief nurse at the 313-bed hospital in Winfield, IL.
The initiatives include redesigning the care coordination model as well as starting daily, multidisciplinary rapid rounds and weekly long-stay meetings, Haviley says.
The hospital also has developed detailed protocols that list what type of interventions should occur each day for patients with specific diseases and types of problems.
"We mapped out the care so all staff are on board and understand what the plan of care is. We have pre-printed orders to help physicians think about care that is based on evidence in the literature and what we want to emphasize prior to the patient leaving the hospital," she says.
The hospital's new care coordination model, being rolled out gradually unit by unit, defines specific roles for the care coordination team and refines the roles of the utilization management nurse, the case manager, and the social worker, she says.
"We looked at the various models for care coordination and opted to separate the roles of the utilization manager, the case manager, and the social worker, with the exception of the intensive care unit. Our intent is to be very clear and descriptive about what needs to be done at what point and by which discipline," Haviley says.
Before the department was reorganized, Central DuPage Hospital's care management process was a blended approach, she says.
"Sometimes there were two people working on the same issues. We didn't specifically define the utilization management role so all the case managers took that on, causing the potential of replication efforts and reduction in efficiency. When we reorganized the department, we clearly defined who does what to eliminate any duplication of effort," she says.
Representatives from the entire case management department and the nursing department were involved in the redesign of the model and had input every step of the way.
The team developed a grid to guide the work of the care coordination team to make sure patients receive the right resources at the right time.
"The grid shows that as the case becomes more complex and complicated, we call in more resources," she says.
The utilization manager is responsible for identifying patients' financial resources and the kind of support patients might need from insurance coverage and other payer sources.
Case managers have the same information, but they concentrate on working with the staff to facilitate discharge planning.
Social workers are called in on more complex cases, such as when patients have a complicated family situation, transportation issues, or extensive discharge planning needs.
The team analyzed the workload on every unit in the hospital and determined how to use the existing staff to fill the working components in the new model.
"We took into account that some units have a faster turnover in patients than other units. We spent time looking at the workload and determining how many staff [members] it would take to handle the work on each unit," she says.
Most units are staffed by one case manager, with utilization managers assuming responsibility for two units.
The hospital conducted a demonstration project with the new role definitions on two units and is in the process of rolling out the redesign to the entire hospital.
"We asked for volunteers for the various roles for the project. Some wanted to try something different. Others were interested in being more closely involved in process improvement," she says.
The team emphasized that people who are assigned a new role have the option to change it later on, she says.
"We just reorganized how people are placed, based on their skill sets and their interests. They don't have to stay in their new roles forever. There is always the opportunity to do something different down the road," she says.
Staff from the units that have already gone live with the new role definitions are helping roll out the changes to other units.
"We have developed very specific tools to help them, using input from the team that worked on the first pilot," she says.
In an effort to cut length of stay and speed up discharges, the case management department started holding daily rapid rounds on several units to focus on the discharge needs of all patients on the unit.
The team that attends the 10 a.m. meeting includes the nursing staff, case managers, social workers, and physicians or advanced practice nurses.
"Our meetings are very pointed and targeted, and we have an outcome in mind getting all the important diagnostic tests and treatments completed that need to be done so the patient will be ready for discharge. As a result, we have seen an increase in patient discharges earlier in the day," Haviley says.
One unit discharged 47% of its patients before 3 p.m. in January 2010, compared with 39% in the last quarter of the previous fiscal year. Another unit increased the percentage of timely discharges from 39% to 59%.
The cases are presented by the staff nurses, who rotate their attendance at the rapid rounds. If a staff nurse has four patients on a unit, he or she presents all four then leaves and the next nurse comes in to present his or her cases.
The charge nurse and case manager on the unit facilitate the meetings and provide feedback to the presenters.
The meetings are facilitated by the charge nurse and the case manager, who steer the conversation and also give feedback to the presenters.
The discussion starts with the name of the patient, the diagnosis, the day of admission, how many days the patient has been in the hospital, and what is keeping him or her from being discharged.
"The nurse tells what he or she has been working on, and the rest of the team discusses what they are doing to help get the patient ready for discharge," she says.
The team discusses every patient on the floor every day, looking at barriers to discharge and what needs to be done to expedite the patient that day.
"They aren't talking about the whole case but are intentionally targeting what needs to be done before the patient can be discharged. Everybody is on board, and when they walk out of the room, they know their assigned responsibilities for the day, depending on what each patient needs," she says.
For instance, nursing may be assigned to complete an assessment or medication reconciliation. The case manager or social worker will deal with placement issues.
"When we didn't have rounds, the team sometimes had difficulty finding physicians or support staff to coordinate patient care. When everybody comes together, we don't have to try to locate them," she says.
For instance, if the labs need to be redrawn or the patient needs a physical therapy assessment before discharge, someone on the team takes responsibility for making sure it gets done.
At 2 p.m., the team regroups quickly with the charge nurse and the case manager for a short recap of what tasks were completed during the day and what unresolved issues need to be tackled by the next shift.
If there are interventions that need to be done during the evening shift, the nurses make a note of it and discuss it at shift change. The next morning, they report on what was accomplished overnight.
"We are very disciplined with the process, and everybody takes their assigned tasks seriously," she says.
The hospital's weekly long-stay meetings focus on patients who have been in the hospital for seven days and those who are expected to be in the hospital for more than seven days.
The case manager presents the cases to the long-stay team, which includes the vice president of quality, two associate chief nurses, the manager of case management, and physicians when they can be present.
"We don't present every case. We focus on patients who have some kind of roadblock to going home. We don't discuss the cases where they have complications that require them to stay," she says.
For instance, the team discusses patients who are having difficulty coping with their illness or injury, as well as those who have family issues or may need resources to support them after discharge.
For instance, one patient is a young mother with children at home who was severely injured in an automobile accident. The team helped the family come up with post-discharge options for the woman's care.
"When a family is facing a difficult situation, they don't know about all the options that are available to them. The team is there to help. The patient may need to go to an extended care facility, to receive hospice care, or home health support. We call on the physicians to help explain the complexity of the problem and plans for the future. We often call on the chaplain to help with emotional issues," she says.
[For more information, contact: Corinne Haviley, RN, MS, associate chief nurse, Central DuPage Hospital, e-mail: firstname.lastname@example.org.]