Team huddles improve LOS, core measures

All units follow same procedures

After Springfield Regional Medical Center in Springfield, OH, began daily multidisciplinary team huddles to facilitate patient care, the hospital’s performance on targeted core measures rose to the 95th quartile compared to a range of 75% to 81% when the project began, and the housewide ratio of the observed-to-expected length of stay decreased from 1.15 to 1.07.

“Our goal with this project was to bring consistency to each unit throughout the hospital, increase our adherence to core measures, and create the best quality care for all patients. We knew that Medicare’s value-based purchasing program was coming, and we wanted to be well positioned to succeed. The units all had different processes and we saw a lot of opportunities to standardize processes throughout the hospital,” says Holly McGowen, RN, BSN, performance improvement nurse coordinator for quality and case management for the 284-bed hospital.

The process was designed by a committee that included the unit directors, unit managers, charge nurses and case managers on the unit as well as representatives of every ancillary department. They met to discuss what happens with patients from their perspective from admission to discharge, what responsibilities they have for ensuring core measures compliance, and what needs to happen for the patients to move through the continuum as efficiently and safely as possible.

The team targeted core measures for acute myocardial infarction, heart failure, pneumonia, and the surgical care improvement measures and looked at ways to ensure that patients get the care they need in a timely manner.

The hospital began with a pilot project on the 23-bed step-down unit, which generally had a high length of stay and a lot of opportunities each month for improvement on core measure compliance.

A key part of the process was implementing daily multidisciplinary team huddles, facilitated by the case manager and the charge nurse, during which every member reviews every patient. “It takes a whole team working together to provide good patient care. During the huddle, the team works together to develop care plans, follow-up on care plans, and improve patient flow through the system by addressing patients’ needs in a timely and precise fashion,” says Susan Molloer, RN, manager of quality and case management.

The director or manager in each ancillary department selected one colleague to represent the department at the daily huddle. The departments can include case management, nursing, nutrition, palliative care, pharmacy physical therapy, occupational therapy, quality, respiratory services, wound care, and spiritual care.

The charge nurse and the case manager always attend the huddle on their unit. Ancillary services participate where they are most needed. For instance, physical therapy is always represented at rounds on the surgical unit. Respiratory services always has a representative when the team rounds on patients in the intensive care unit or step-down unit who are on ventilators or who have breathing problems. A hospice liaison is available for medical oncology rounds.

“We try to utilize the ancillary departments’ expertise and have them participate in patient huddles where they are most needed,” McGowen says.

When the pilot project began, the team on the step-down unit developed a series of tools to help facilitate the improvement process and make sure that nothing falls through the cracks. These include a huddle sheet with boxes for diagnosis, admission date, place of residency before admission, and applicable core measures. The huddle sheet is updated daily. Other tools include a referral sheet with spaces for referrals for each discipline, and a huddle log that summarizes core measures components.

The team created color-coded core measure order sets (orange for acute myocardial infarction; green for heart failure, pink for pneumonia, and blue for surgical care improvement project measures). The unit created colorful educational bulletin boards in a “Core Measures Corner” featuring reference tools for nurses to remind them to ensure core measures compliance. The unit selected core measures champions for each measure and implemented monthly core measures meetings during which the champions educate the staff on changes in the core measures as well as performance on the unit.

During the first 60 days, the length of stay decreased by 20% and the number of opportunities for improvement on core measures compliance dropped from seven to three.

After the pilot in April 2010, the process and all the components of the pilot project were rolled out across every unit in the hospital by August 2010.

“We’re taking a proactive approach to patient care and look at the patient’s progress and the needs of the day every morning. Quality and case management are working together to drill down on readmissions and opportunities for improvement in the discharge process,” Molloer says.