Barrier reduction teams smooth throughput

Staff are empowered to make changes

After New York Presbyterian Hospital developed barrier reduction teams on each service to determine reasons for delays in the discharge process and come up with solutions, the average length-of-stay hospitalwide dropped by half a day and patient satisfaction scores increased.

Having teams on each service identify barriers in the discharge process and collaborate on overcoming the problems has the added bonus of making the hospital staff feel empowered to make changes, says Katherine Pavlovich, MPH, project manager, department of quality improvement and innovation for the 2,049-bed hospital.

“Staff members no longer think that issues are someone else’s problem or that it’s up to the hospital to solve them. Now they work together to fix problems that occur on their unit,” she says.

The hospital began looking at ways to increase efficiency in the discharge process in late 2009 and assembled a multidisciplinary team including case managers, social workers, nurses, and therapists to analyze the hospital’s demand and capacity. The first step was implementing morning bed huddles by admitting and nurse managers from all units that admit patients, Pavlovich says. The nurse managers shared information on pending discharges at the huddle, and the admitting representative shared the predictions for the number of people who would need to be placed on a unit during that day.

“This worked very well in terms of getting everybody on the same page about patients who were leaving and being admitted each day, but many times, the number of admissions and discharges anticipated in the morning was different from what happened during the day. We knew we had to come up with a way to address the underlying issues that were causing the differences,” she adds.

The hospital developed barrier reduction teams on each service to identify barriers in the discharge process, determine what was causing the delays, and come up with ways to improve the issues. A nurse manager from each service facilitates the meetings. “The nurse managers were chosen for their leadership ability. We wanted to make sure that people who served in that capacity had the desire and the skill set necessary to drive the team,” Pavlovich says.

Each service has its own barrier reduction team which includes the staff that can most affect throughput, says Carol DeJesus, MSW, LCSW, ACSW, CCM, director of social work and care coordination. Care coordinators, social workers, and nurses are on every team. Ancillary departments and physicians participate depending on the service.

“We got the entire team involved. Instead of the care coordinators being the only ones to look at barriers and chase down ways to overcome them, the whole team is working together,” DeJesus says.

The nurse managers compile a daily report detailing the anticipated and actual discharges on the service, and the team looks at what causes the difference between the estimated discharges and patients who actually go home. In the beginning, the barrier reduction teams on the individuial services met every week to discuss the report and identify trends and ways to improve the process. Pavlovich, DeJesus, and one of the directors of nursing attended each meeting. “In the beginning, we were the liaisons between the different services. We talked with each team about their challenges and their successes and identified hospitalwide trends,” she says.

Now the individual teams on each of the 10 services collect the information daily and meet biweekly. The role of the members of the team is to go back to the clinicians on the service and share what was discussed. The nurse managers who lead the service teams meet monthly to discuss trends and brainstorm on solutions and attend quarterly meetings with the patient care services director.

“As we began to meet, we got to know each other and the processes throughout the hospital and where the glitches occurred. Because of teamwork, we were able to create simple solutions,” DeJesus says.

The initiative was accomplished without additional staff. “It was a matter of getting the structure in place, meeting regularly, and giving the staff ownership and empowerment,” Pavlovich says.

Some of the changes the services made as a result of the barrier reduction teams were small but very important. Others have been rolled out across the entire hospital, Pavlovich says. (Bedside walking rounds are one initiative that is being implemented throughout the hospital. For details, see story below.)

For instance, patients on the pediatric services often could not be discharged until the team determined that they could tolerate a meal. When lunch was served at 12:30 or 1, it often delayed the discharge because the physician had to see the patient and write discharge orders after the meal. “Now nutrition delivers lunch early in the day for patients who are being discharged,” Pavlovich says.

The surgical barrier reduction team determined that while the staff on the service generally understood what should happen with patients on each post-operative day, there wasn’t consistency among the treatment team members.

“Based on feedback from the barrier reduction team, the surgical service developed care guidelines and educated everyone on the service about the standardized plan of care,” she says. Now all the teams throughout the hospital are working on standardized care pathways. “We picked out a few DRGs and saw a reduction in the length of stay as soon as the standardized care guidelines were implemented,” Pavlovich says.

Before the initiative, patients in the cardiac area were being evaluated by physical therapy on Day 1 after surgery, a practice that the barrier reduction team changed. “Many times, they were coming out with a recommendation that didn’t truly reflect that patient’s capabilities. That meant that social workers spent their time getting placements for patients who didn’t need them or having to get placements at the last minute for patients who did,” DeJesus says.

The orthopedics team developed pathways around pain control and physical therapy orders and standardized care. The changes reduced the average length of stay for knee replacement patients by a day, DeJesus says.

The process has empowered everyone in the hospital to bring his or her issues to the barrier reduction teams and work on solutions, DeJesus says. “When initiatives are a team effort, it’s much easier to get buy-in,” she adds.

Bedside rounds improve communication

LOS has decreased, satisfaction is up

As a result of the barrier reduction teams, every service at New York Presbyterian Hospital has implemented bedside walking rounds at a set time each day when the entire treatment team visits patients’ rooms and discusses their progress, their treatment plan, and their anticipated discharge.

“This initiative has improved communication between the treatment team, the patient, and the family and has led to a decrease in length of stay and an increase in patient satisfaction scores. Families know when the team is going to make rounds and can be there,” says Carol DeJesus, MSW, LCSW, ACSW, CCM, director of social work and care coordination.

The team does not hold bedside rounds on every patient every day. Instead, the care coordinator on the unit reviews the records each morning and determines which patients should be included in the bedside rounds and leads the rounds, focusing on the pertinent issues. Many times, the patients targeted are the most complex medically or those getting ready for discharge. However, if a patient has cognitive deficits, the team may skip the bedside rounds and communicate with the family another way.

The bedside rounds are short, but if the patient has a question, the clinician who can answer it comes back later. “The team doesn’t have a long conversation with the patient and family members, but they hear the same message from all the team members. In the past, each team member may have said the same thing, but if they used different language, it confused the patients,” she says.