Discharge Huddles: How Every Patient, Every Day Impacts Los, Patient Flow & Staff Engagement Kate Vogl, MHA; Sara Scott, RN; Cindy St. George, MSW; United Hospital, St. Paul, MN METHODS AND MATERIALS
OBJECTIVES
Standard Work: DC Huddle Seq. Task No Description
1
UNDERSTANDING THE WHY? 3.1
3.2
Implementation Process
CONTACT INFO Cindy St. George MSW, LICSW, ACM Director of Care Management Allina Health United Hospital St. Paul, MN 55102 Cindy.St.George@Allina.com 651-241-8585 We have a short presentation to provide aa visual of the interdisciplinary process in action. A short 2 to 3 min clip highlights the efficiency and effectiveness of having a consistent structured format.
Welcome Team and Remind Purpose of Huddle
1 20-30 min
All
2
• Stay focused on discharge • Identify opportunities and barriers • Escalate appropriately • Finish in 15-18 minutes (30 sec. per patient) ** For this test period, all participate in post huddle debrief
Social Worker
0:30
3.3
Discharge plan
RN Care Coordinator
0:10
Social Worker
0:05
• Where Pt. came from if new? • Where Pt. discharging to?
• Plan for day • Nursing care (1:1s, restraints, IV to oral meds, mobility) • Plan for stay All with • C onsults needed? (PT, OT, Speech) What’s information • P harmacy alerts? keeping pt. • Risks or concerns from Transition conference (Social in hospital? worker workbench report to trigger action/intervention facilitate) • LACE score + other concerns • Anticipate transition conference needed? • Barriers to d/c • Clinical progression, discharge destination etc.
All: Collect Updates on all action items from am DC huddle Begin Loopback • Confirm planned morning discharges for next day Welcome Team and • Identify and assign evening discharge tasks Remind Purpose of • Notify Provider Loopback • No longer than 15 minutes ** For this test period, provide feedback on process Complete the following for each patient
4
Review to-dos
Charge RN
All
5:00
Social Worker
0:30
Charge
0:05
Charge
0:10
Prepare
Lead discussion using action item template
• Room # • action item (completed or not) • barriers to action
• What’s the plan? – Location If discharging today – Time or tomorrow? • Who’s doing what? • Who’s contacting the physician? After review of all patients
4
• Who are appropriate for what time? – 9am – 10am – 11am • Barriers to Escalate
Review To-Dos
All
1:00
Discharge Huddle Action Item Template 0:15
Date:
07 Charge:
Room#
Complete the following after each unit • To-dos per role • D/Cs for today • D/Cs for tomorrow (potential early AM D/Cs if known) • Barriers to escalate
3.2
Who
Task Time mm:ss
Key Point / Image / Measure (what does good look like?)
Task Description:
3.1
• Room # • Name Patient iagnosis information •• D LOS, DRG, ADD • Lace
0:30
LOS
DRG
LACE
SW To DO:
15 Charge: Charge RNCC RN To To Do: Do:
23 Charge: DC DC Loopback: AM DC Today Tomorrow AM DC Success?
4504 4506 4508 4510 4512 4514 4516
Connects the work between DC Huddle (15 min. a.m. meeting and Loop Back (5 min. afternoon meeting).
RESULTS DRG Discussed in Discharge Huddle
Duration of Discharge Huddle 2018
45 40 35 30 25 20 15 10 5 0
2017
2018
80
2018
2017
20-24 min
40
30
30
20
20
10
10
0
0
0-25%
25-30 min
26% time reduction in DC Huddle duration
25-50%
50-75%
2018
75-100%
0-25%
25-50%
50-75%
75-100%
73% increase in LOS discussed in DC Huddle
74% increase in DRG discussed in DC Huddle
ADD (Anticipated DC Date) Discussed in DC Huddle
2018 Planned A.M. DC (Before Noon) 400
2017
350
250
324
311
383
335
287
300 250
328 287
344
346
284
248 200 150
0-25%
25-50%
50-75%
75-100%
Jan-18
Feb-18
Mar-18
“The overall process is much clearer, and we are focusing on discharge. We walk away with a plan, not just reviewing barriers without knowing who is going to do what to having to address them.“ – Nurse Manager, Neuro Step down unit
DISCUSSION 1. The standard work for discharge huddle was the key to our discharge huddle success and impact on metrics. All members of the care team found it to be an important and valuable tool. 2. Although the daily morning meeting was called “discharge” huddle staff found that when we improved the process, how little previously there was meaningful discussion on discharge planning. The focus of the conversation had drifted back to a review of nursing report. 3. Staff were initially cautious and hesitant about using “standard work” but after using the tool on a daily basis found that it is the key to having a consistent, efficient process where everyone on the team is on the same page. 4. Results were impressive: we achieved our goals of a defining an efficient effective, sustainable approach to support our hospital wide goals of decreasing LOS, patient flow (planned a.m. discharges and ensuring role clarity).
HOW TO REPLICATE THE WORK
50
40
15-19 min
“I was hesitant at first but really like the new process. I have a clear plan leaving discharge huddle.” – RN Care Coordinator
2017
60
50
10-14 min
“With this new process I don’t feel like discharge planning is solely mine to own. Everyone has a part.” – Social Worker
70
60
>30 min
100 90 80 70 60 50 40 30 20 10 0
LOS Discussed in Discharge Huddle
70
133% increase in ADD discussed in DC Huddle
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Seq. No
Complete the following for each patient
Summary of Project
• Baseline data from 2017 DC huddle audits were compiled to determine • Pilot was initiated on 2 medical units in August & September of 2018. • The next step to spread new discharge huddle process using standard work to all medical surgical units in November and December. New DC huddle would spread to a total of 12 units, approximately 300 pts, approximately 85% of our average daily census. • Roll out to other units were staggered starting the first week of November with all units updated with new DC huddle process by end of December. • First Quarter of 2019 post implementation data collected to show broader comparison data from baseline 2017 data
Task Time mm:ss
Begin Huddle
2
Utilizing LEAN principle of standard work, develop a sustainable, effective and efficient process for multi-disciplinary discharge huddle to impact LOS, planned a.m. discharges and staff engagement.
Who
• All: have census and content for huddle prepared • RNCC: prepare highlights from the transition conference workbench report • Charge RN: listening for appropriate timing for tomorrow’s discharges and nursing to-dos
Prepare
Quotes from care team members:
Standard Work: Loop Back
Key Point / Image / Measure (what does good look like?)
# Discharges
• Develop and implement a realistic and standard approach to multidisciplinary discharge huddle • Reduce the overall time spent in discharge huddle while increasing clarity and focus of patient discharge goals. • Hardwire process by creating standard work to ensure role clarity and sustainability • Increase number of planned a.m. discharges
STAFF ENGAGEMENT
Apr-18
May-18
Jun-18
Jul-18
Aug-18
Sep-18
53% increase in planned morning discharges in 2018
Oct-18
Nov-18
Dec-18
• The key to creating a successful spread of the work is in creating and ensuring adherence to the standard work for each discipline. • Provide staff with standard work and meet with care team 2 week before go live to review standard work, set expectations and answer questions. • Care Management leadership and Performance Improvement advisor monitored during the first 2 week implementation process to provide daily real time feedback, ensure standard work was being followed and to completed data tracking.