General Pediatric Discharge Time Project IHQI Seed …...M General Pediatric Discharge Time Project IHQI Seed Grant Symposium May 5, 2015 Kathleen Bradford, MD Heidi Troxler, MSN,

U N

C H

E A L T H

C A

R E S Y S T E M

General Pediatric Discharge Time Project

IHQI Seed Grant Symposium

May 5, 2015

Kathleen Bradford, MD

Heidi Troxler, MSN, RN

Sheryl Galin, BSN RN

Jennifer McElroy, MSN, RN

Kevin Kelly, MD

Melanie Dawes MBA, MHA, RN

Ian Buchanan, MD, MBA

Problem Statement:

Patient discharges on the General Pediatric

Services occur late in the day.

In calendar year 2012, < 2% of Pediatric Medical A

(PMA) discharges occurred before 1100, and

approximately 60% occurred after 1500.

PMA Patient Diagnoses and Conditions

• Pediatric Medicine A- General Pediatrics

• Pediatric Metabolic Disease

• Pediatric Rheumatology

• Pediatric Infectious Disease

• Pediatric Neurosurgery 8/2013

• Pediatric Nephrology- 9/2014

Problem Statement:

Global Aim Statement:

To increase the number of hospital discharges

by 1 PM on the General Pediatric Medical

Service (PMA) to 50%

Smart Aim Statement:

To improve the mean discharge time

of PMA patients

Hospital Discharge Process is Complicated!

Physical Process Map

Attending

Computer

HUC

Ancillary staff

CCMRN

Residents

WTC

Patient & Family

• Acute/ Chronic illness improved /stable

• Medication Reconciliation/Plan

• Home Health Plan

• Rounds-Attending/ Team see patient

• IV or other devices removed

• Prescriptions e -scripted to right home

pharmacy

• Prescriptions sent to hospital pharmacy

• Consultant/s sign off

• GT/PICC/ CVL Teaching

• Home supplies delivery confirmed

• PCP/consultant/ f/u scheduled

• Disposition – Custody issues

• Discharge Order Written

• Ride arranged/ available

• Bags packed

• Meals/ showers

• Car Seat secured

• Discharge Cart available

• Car obtained from parking lot

Medically Ready

Family Ready

Aug20

13

Jul2013

Jun2

013

May201

3

Apr2013

Mar20

13

F eb20

13

Jan2

013

Dec201

2

Nov2012

Oct2012

Sep20

12

Aug2012

Jul201

2

Jun2

012

May201

2

Apr2012

Mar20

12

Feb2012

Jan2

012

5:00 PM

4:00 PM

3:00 PM

2:00 PM

Month

Mea

n d

isch

arg

e ti

me

by

mo

nth

__X=3:36 PM

UCL=4:55 PM

LCL=2:17 PM

What time are PMA patients discharged?

D M A I CPMA Discharges

2012 Baseline

Mean=3:36 PM

3 standard errors

12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am

200

150

100

50

0

Hour of day

Fre

qu

en

cy

Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 4/15/2015 4:50:24 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]

What time were PMA patients discharged before improvements began?

1/1/2012-9/28/2013

n=1381

Mean 15:36 PM

17% before 1PM

N=1381

D M A I C

SMART AIM KEY DRIVERS INTERVENTIONS

To increase the

percentage of PMA

patients who are

discharged before

1PM once they are

identified as medically

ready for discharge

from NCCH.

Continue to identify

discharge barriers

and establish plans to

mitigate these

barriers

Revision 3.2015 KKBHBT)

Improve the

discharge process

and improve overall

patient flow through

NCCH

GLOBAL AIM

• * Identification and mitigation of process failures

Recommended Future Interventions

• Discharge Medication Improvement

• Development of standard EMR Discharge Criteria for

high impact Pediatric diseases “discharge stamp”

Empower the entire

medical team and

families in the

discharge process.

• Develop Spread plan

• Feedback discharge run charts to medical team

Create a system and

culture in which

patients ready for

discharge are

prioritized.

•Kaizen event to decrease time between discharge order

and physical discharge from NCCH

•Charge nurse to script “Steps to Home” with families after

AM huddle

• Clearly define roles in discharge process, hold all team

members accountable. Enable night team.

• Implement 6CH 8:30 AM Multi-disciplinary Discharge

Huddle

• Determine patients medically ready for discharge before

AM rounds.

• Discharge patients medically ready for discharge during

AM huddle or on teaching rounds

Discharge Time Improvement Project (DIP)

Apr15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12

8:00 pm

6:00 pm

4:00 pm

2:00 pm

12:00 pm

Tim

e o

f d

ay

__X=2:39 pm

UCL=4:51 pm

LCL=12:28 pm

Improvements began

Project: PMA&PMB.MPJ; Worksheet: PMAasoflastweek; 5/1/2015 8:23:49 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]

Weekly Mean PMA Discharge Time

Mar15

Feb15

Jan1

5

Dec14

Nov14

Oct14

Sep14

Aug14

Jul1

4

Jun14

May14

Apr14

Mar14

Feb1

4

Jan14

Dec13

Nov13

Oct13

Sep13

Aug1

3Ju

l13

Jun1

3

May13

Apr1

3

Mar13

Feb13

Jan1

3

Dec12

Nov12

Oct12

Sep1

2

Aug12

Jul1

2

Jun1

2

May12

Apr1

2

Mar12

Feb1

2

Jan1

2

5:00 PM

4:00 PM

3:00 PM

2:00 PM

1:00 PM

12:00 PM

11:00 AM

Tim

e o

f d

ay

3:09 PM*

began DC order tracked

Mean PMA DC time

Mean PMA DC order timeMean PMA Discharge Time by Week

**Mean PMA DC time last week

***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/16/2015 11:35:01 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]

*Mean PMA DC time since 1/1/2012

Improvements Epic Go-Live &

2:26 PM**

1:03 PM***

Maintaining Gains & Continuing Improvement

• Kaizen (LEAN) event February 23-27, 2015

• Decrease time between D/c order and physical discharge

• Current State- 1hr 44 minutes

• Culture change in process- discharge is

priority.

• Family delays- restaurant delivery,

showers, packing.

• Staff Delays- Unit clerk notification to

nurse of discharge order, discharge

cart.

• Ongoing areas for improvement-

Discharge medication

• Dietary Staff cannot see discharge

order

• Scripting for nursing/ medical team for

anticipated discharges

• “Steps to home” education sheet for

families

• Staff education

• CCM pilot of arranging transportation

in some cases

• Use EPIC anticipate discharge order

for next day’s anticipated discharges

• Record attendance at morning

discharge huddles

• Investigate process of take away

meals

Insight Action

Time from discharge order to actual discharge—97

minutes during week of Kaizen

Family Education Sheet

Apr1

5

Mar15

Feb1

5

Jan1

5

Dec14

Nov14

Oct14

Sep1

4

Aug1

4Ju

l14

Jun14

May14

Apr14

Mar14

Feb14

Jan1

4

Dec13

Nov13

Oct13

Sep13

Aug1

3Ju

l13

Jun13

May13

Apr13

Mar13

Feb13

Jan1

3

Dec12

Nov12

Oct12

Sep12

Aug1

2Ju

l12

Jun12

May12

Apr1

2

Mar12

Feb12

Jan1

2

5:00 PM

4:00 PM

3:00 PM

2:00 PM

1:00 PM

12:00 PM

11:00 AM

Tim

e o

f d

ay

began DC order tracked Discharge Kaizen

3:07 PM*

Mean PMA DC time

Mean PMA DC order time

Mean PMA Discharge Time by Week


***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 4/20/2015 12:19:38 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]

Improvements


Epic Go-Live &

2:26 PM**

12:42 PM***

As of 04/18/2015

12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am

200

150

100

50

0

Hour of day

Fre

qu

en

cy


9/29/13-4/18/15When are PMA patients discharged now?

n=1439

Mean discharge time=2:39 pm

32.38% discharged before 1 pm

Mean 14:39 PM

9/29/2013-5/2/20151/1/2012-9/28/2013

After 1 pmBefore 1 pmAfter 1 pmBefore 1 pm

1200

1000

800

600

400

200

0

Nu

mb

er

of

dis

ch

arg

es

998

477

1150

231

Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 5/5/2015 8:45:38 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]

PMA patients discharged before and after 1 pm

17%

83%

32%

68%

Results

Are results significant?

• Differences between discharge times before and after the

Green Belt project continue to be statistically significant.

• Differences from Kaizen are not currently statistically

significant.

Percent of

discharges

before 1 pm

Mean

discharge

order time

Mean time

from DC order

to actual DC

Total

discharges

Average

discharge

time

Before

(1/1/12-

9/28/13)

17 2:06 pm in

2012

1 hr 44 min in

2012

1381 3:36 pm

After GB

(9/29/13-

02/21/15)

32 1:05 pm 1 hr 46 min 1281 2:41 pm

Kaizen

(02/22/15-

04/25/15)

34 12:42 pm 1 hr 42 min 174 2:24 pm

Mar15

Dec14

Sep14

Jun14

Apr14

Jan14

Oct13

Jul1

3

Apr13

Jan13

Oct12

Jul1

2

Apr12

Jan1

2

6

5

4

3

2

Me

an

len

gth

of

sta

y (

da

ys

)

_X=3.745

UCL=5.601

LCL=1.889


Length of stay for PMA patients

January 2012-March 2015

Challenges/ What We Learned

1. Reaffirm that Discharge is complex/complicated

process

• Break down process with multiple PDA cycles

2. Discharge Huddle has been very effective

3. Early communication with Charge Nurse/ CCM

4. Cultural Change/Late Adopter

• “Work of day” has shifted to the AM

• Ongoing feedback to the teams

5. Patient Specific Discharge Goals or “Green Sheets”

Project “ hot potatoes”

Challenges/ What We Learned

6. Spread - PMB team

7. Epic Roll Out

8. Weekends

• Expectations are different on the weekends

9. Resources

• Discharge take away meals

•Discharge carts

6. Future PDSA/PDCA cycle focus

• Discharge patients when they are medically ready

• EMR patient specific goals- Discharge Stamp

• Discharge Medication Process

• Night Attendings

PMA Discharge Time Project Team

IHQI Center; Laura Brown, MPH; Tina Willis, MD; Mike Pignone, MD

Kevin Kelly, MD, Pediatrician In Chief

Acknowledgements

U N

C H

E A L T H

C A

R E S Y S T E M

Appendix

Apr1

5

Mar15

Feb1

5

Jan1

5

Dec14

Nov14

Oct14

Sep1

4

Aug1

4Ju

l14

Jun14

May14

Apr14

Mar14

Feb14

Jan1

4

Dec13

Nov13

Oct13

Sep13

Aug1

3Ju

l13

Jun13

May13

Apr13

Mar13

Feb13

Jan1

3

Dec12

Nov12

Oct12

Sep12

Aug1

2Ju

l12

Jun12

May12

Apr1

2

Mar12

Feb12

Jan1

2

5:00 PM

4:00 PM

3:00 PM

2:00 PM

1:00 PM

12:00 PM

11:00 AM

Tim

e o

f d

ay

began DC order tracked Discharge Kaizen

3:07 PM*

Mean PMA DC time




***Mean PMA DC order time last weekProject: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 4/20/2015 12:19:38 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]

Improvements


Epic Go-Live &

2:26 PM**

12:42 PM***

As of 04/18/2015

Mar15

Dec14

Sep14

Jun14

Apr14

Jan14

Oct13

Jul1

3

Apr13

Jan13

Oct12

Jul1

2

Apr12

Jan1

2

6

5

4

3

2

Me

an

len

gth

of

sta

y (

da

ys

)

_X=3.745

UCL=5.601

LCL=1.889


Length of stay for PMA patients

January 2012-March 2015

Mar15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12Jul12Apr12Jan12

5:00 pm

4:00 pm

3:00 pm

2:00 pm

1:00 pm

5.0

4.5

4.0

3.5

3.0

2.5

Mo

nth

ly m

ea

n D

C t

ime

(ti

me

of

da

y)

Le

ng

th o

f s

tay

(d

ay

s)

Monthly mean DC time

Monthly mean LOS


PMA patients, January 2012-March 2015Mean Discharge Time and Length of Stay by Month

PMA Discharge Times: July 2014-present

Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14

5:00 pm

4:00 pm

3:00 pm

2:00 pm

1:00 pm

12:00 pm

Tim

e o

f d

ay

__X=2:16 pm

UCL=4:05 pm

LCL=12:26 pm

Before Kaizen After Kaizen

1

Project: PMA&PMB.MPJ; Worksheet: PMA062914-032115; 3/23/2015 3:25:57 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]


n=697

Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14Jun14

3:00

2:00

1:00

Tim

e fr

om

ord

er t

o d

isch

arg

e

__X=1:48

UCL=2:36

LCL=1:00

Kaizen

2

1

Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 6:54:59 PM; Heidi Troxler, N.C. Children's Hospital, [email protected]

Weekly mean time between discharge order and actual discharge

PMA patients, 06/29/14-03/21/15

Time from discharge order to actual discharge

n=697

PMA Discharge Times: January 2012-present

Mar15

Feb15

Jan15

Dec14

Nov14

Oct14

Sep14

Aug1

4Ju

l14

Jun1

4

May14

Apr1

4

Mar14

Feb14

Jan14

Dec13

Nov13

Oct13

Sep13

Aug13

Jul1

3

Jun13

May13

Apr13

Mar13

Feb1

3

Jan1

3

Dec12

Nov12

Oct12

Sep1

2

Aug1

2Ju

l12

Jun12

May12

Apr1

2

Mar12

Feb12

Jan12

8:00 pm

6:00 pm

4:00 pm

2:00 pm

12:00 pm

Tim

e of

day

__X=2:16 pm

UCL=4:05 pm

LCL=12:26 pm

Green Belt Kaizen

1

2

2

2

22

2

2

22

1

2

2



n=2739

Discharge order vs. actual discharge

Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14

4:00 PM

3:00 PM

2:00 PM

1:00 PM

12:00 PM

11:00 AM

Tim

e o

f d

ay

Mean PMA DC time




n=697

Background

• Results of Green Belt project on PMA discharges presented to this

committee in October 2014

• Key interventions from that project:

• Nursing and CCM at 1500 rounds

• Day team completes tasks for next day’s discharges

• Implement 0830 discharge huddle

• Patients discharged before or during rounds if clinically ready

• Night team rounds on next day’s anticipated discharges &

completes any discharge tasks

• Mean discharge time went from 3:36 pm to 2:40 pm, p<0.01

2.14

2.64

3.14

3.64

4.14

4.64

5.14

5.64P

MA

LO

S

PMALOS Jan12.April14

Balancing Measure PMA LOS

PMA LOS

Average

Mar15Feb15Jan15Dec14Nov14Oct14Sep14Aug14Jul14Jun14May14Apr14Mar14

5:00 PM

4:00 PM

3:00 PM

2:00 PM

1:00 PM

12:00 PM

11:00 AM

Tim

e o

f d

ay

2:45 PM**

3:10 PM*

Mean PMA DC time


Mean PMB DC time

Mean PMB DC order time

Mean PMA & PMB Discharge Times by Week

*Mean PMB DC time since 3/2/2014

**Mean PMA DC time since 3/2/2014Project: PMA&PMB.MPJ; Worksheet: PMA&PMBbydate; 3/23/2015 10:01:40 AM; Heidi Troxler, N.C. Children's Hospital, [email protected]

As of 03/21/15

Mar15

Dec14

Oct1

4Ju

l14

Apr1

4

Jan14

Oct1

3Ju

l13

Apr1

3

Jan1

3

Oct1

2Ju

l12

Apr12

Jan1

2

4:00 pm

3:00 pm

2:00 pm

Tim

e o

f d

ay __

X=3:08 pm

UCL=4:08 pm

LCL=2:07 pm

1

1

2

2


Tests performed with unequal sample sizes

Mean PMA Discharge Time by Month

Apr15Jan15Oct14Jul14Apr14Jan14Oct13Jul13Apr13Jan13Oct12Jul12Apr12Jan12

8:00 pm

6:00 pm

4:00 pm

2:00 pm

12:00 pm

Tim

e o

f d

ay

__X=2:17 pm

UCL=3:58 pm

LCL=12:35 pm

Improvements began Discharge Kaizen

1

2

2

2

222

2

22

1

2

2


Mean PMA Discharge Time by WeekAs of 04/18/2015

12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am

200

150

100

50

0

Hour of day

Fre

qu

en

cy



n=1439



12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am

200

150

100

50

0

Hour of day

Fre

qu

en

cy


What time were PMA patients discharged before improvements began?

1/1/2012-9/28/2013

n=1381



12:00 am8:00 pm4:00 pm12:00 pm8:00 am4:00 am12:00 am

200

150

100

50

0

Hour of day

Fre

qu

en

cy



n=1439



Documents

General Pediatric Discharge Time Project IHQI Seed …...M General Pediatric Discharge Time Project IHQI Seed Grant Symposium May 5, 2015 Kathleen Bradford, MD Heidi Troxler, MSN,