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Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management
April 2018
• Michelle Cline, RN, MSN, Care Model Redesign Manager• Donna Litwinski, PT, Master Lean Fellow
Objectives
• Operationalize Care Model Redesign with a supporting Lean Management System
• Illustrate consistent job performance in daily processes that support patient experience, safety and progression
• Demonstrate how to make results more transparent and actionable to improve patient outcomes
Static Map3
MemorialCare Long Beach Medical Center
Our Patient Population
LBM (Long Beach Memorial) – 453 Beds• 20,560 Admissions• 108,000 ED visits• 17,000 surgeries
MCWHLB (Miller Children’s & Women’s Hospital Long Beach) – 357 Beds• 15,449 Admissions• 6,000 Deliveries• 8,000 Pediatric Admissions• 84,000 OP visits
• Adult 60% Medicare• Adult 27% Medicare-Medi-Cal
• Peds: 70% Medi-Cal patients • 296 Homeless Adult patients
(average daily census of 9)
LIVES TOUCHED = 100,000+ Patients
Area Involvement/participation 5th Floor (Med/Surg/Resp) Pediatrics (Miller West and CORE) Intensive Cardiac Care Cardiac Monitor Unit 4th Floor (Neuro, Ortho, Wound Care) 6th Floor (Oncology, Surgical) Mother Baby Perinatal Specialty Care Labor and Delivery Intensive Care Cardiac Care Inpatient Rehab Facility Emergency Department
Employees Involvement /participation 1400+ Registered Nurses 90+ Patient Care Associates 680+ Interprofessional 100+ leaders
Linkage to Strategic Plan & True North
6
Outcomes
Where we started…..2015
• 2 star Medicare rated hospital• Magnet Deterioration
* 8 out 9 domains were “red”
• # of Hospital Acquired Occurrences • * 481 Falls (with, without injury)
* 261 (CLABSI, CAUTI, HAPI, C-Diff)
• Adults: ALOS 5.6 days (Medicare)
• Pediatric: ALOS 4.2 days
Where we are today…2018• 4 star Medicare rated hospital• Magnet Re-designation
*7 out of 9 domains are “green”
• # of Hospital Acquired Occurrences
* 400 Falls (with, without injury)
* 172 (CLABSI, CAUTI, HAPI, C-Diff)• Adults: ALOS 5.0 days (Medicare)• Adult Discharged to Home meets GMLOS• Pediatric: ALOS 3.9 days
3 Big Initiatives
Care Model Redesign
MemorialCare Hour
Lean Management
System Care Model
Redesign
What is Care Model Redesign?
Redesigning our care model to ensure • quality patient care• coordinated care
(patient/family/care team)• financial resilience
Care Model Redesign Objectives
Communication Coordination1. Perform a comprehensive patient
history assessments – IPA (Interdisciplinary Patient Assessment)
2. Communicate needs across settings3. Collaborate with team members4. Participate in care planning
w/patients & family-every shift5. Plan for smooth discharge
1. Enhance communication among the key interprofessional team members
2. Facilitate the proactive coordination3. Identify progress4. Identify and address barriers5. Enable and empower the care team6. Improve communication with patient
and family
Lamb, 2014, p. 85
Care Model Redesign Process Steps
1. Selected critical care providers and defined the work that led to improved experience, safety, progression
“RN Coordinator of Care”
2. Selected critical processes that impact Patient Experience, Patient Safety, Patient Progression
3. Developed and documented standard work in selected critical processes that captured best practices
4. Trained front line nursing staff
Identified Communication Opportunities
1. Patient/family • What’s important to the patient• Making it visible
2. Nurses• Hand off with emphasis on patient’s goals
3. Interprofessional team• Involvement in patient progression
4. Leadership• Physician Advisors• Clinical Lead• Management
RN Coordinator of Care
Registered Nurses are the hub of the patient
experience & coordinate patient
care throughout the care continuum.
Care Model Redesign
Team Goals & Recs on Patient communication
board
Professional Exchange Report (PER) & review of goals with Patient
Interprofessional Team Care Briefings to discuss
Patient progression
Escalation Rounds to remove barriers to Patient progression
Interdisciplinary Patient Assessment: electronic
communication
Implement Strategies for Care Progression
Setting Goals: Interdisciplinary Patient Assessment (IPA)
Who: All team membersWhat: Asks the patient-What’s important to you? What matters to you?Where: Discussion at bedside When: On admission intake of IPA in first 24 hoursHow: In Electronic Medical Record (EMR)
Care Model Redesign
Professional Exchange Report (PER) & review of goals with Patient
Interprofessional Team Care Briefings to discuss
Patient progression
Escalation Rounds to remove barriers to Patient progression
Implement Strategies for Care Progression
Interdisciplinary Patient Assessment: electronic
communication
Team Goals & Recs on Patient communication
board
Patient Communication Board :Team Goals and Recommendations-Patient Centered
Who: All team members involved with the patientWhat: Develops patient friendly goals to work on nextWhere: In the Electronic Medical Records under Plan of Care for one stop shopWhen: Daily and/or as the plan changesHow: • RN on nights reviews medical plan and IP
recommendations• Patient decides what goals to achieve that
day• Write it on the board
Care Model Redesign
Interprofessional Team Care Briefings to discuss
Patient progression
Works on Care Proression
Escalation Rounds to remove barriers to Patient progression
Professional Exchange Report (PER) & review of goals with Patient
Implement Strategies for Care Progression
Interdisciplinary Patient Assessment: electronic
communication
Team Goals & Recs on Patient communication
board
Hand Off Communication:Professional Exchange Report
Who: On-coming RN & off-going RN What: Discusses agreed goals, any barriers to accomplishing the plan, & what matters to the patientWhere: Discussion at bedside When: Change of shift: AM and PMHow: On-coming RN & off-going RN manages up/introduces one another while assessing; and discussing with patient the plan for the day
Care Model Redesign
Professional Exchange Report (PER) & review of goals with Patient
Escalation Rounds to remove barriers to Patient progression
Interprofessional Team Care Briefings to discuss
Patient progression
Implement Strategies for Care Progression
Interdisciplinary Patient Assessment: electronic
communication
Team Goals & Recs on Patient communication
board
Patient Progression HuddleCare Briefing by Clinical Leader
22
What is a Clinical Leader? • Facilitates daily Care Briefings• Coaches staff with progression of care• Collaborates with Interprofessional
leaders• Identifies opportunities for
improvement
Who: Bedside RN (coordinator of care & also voice of the patient) and Interprofessional team membersWhat: Discusses agreed goals, any barriers to accomplishing the plan, & what matters to the patientWhere: In hallway of unitWhen: Monday thru Friday scheduled time (in the morning)How: Clinical Leader facilitates group
Benefits to InterProfessional Teams
• Addressed patient and family concerns
• Electronic Form to Document Key Discussion Points
• Care Coordination is a 24/7 process
• Established Quality Review Process
Care Model Redesign
Professional Exchange Report (PER) & review of goals with Patient
Interprofessional Team Care Briefings to discuss
Patient progression
Escalation Rounds to remove barriers to Patient progression
Implement Strategies for Care Progression
Interdisciplinary Patient Assessment: electronic
communication
Team Goals & Recs on Patient communication
board
Escalations Rounds with Leadership Involvement
Who: Unit Clinical Leads, Nursing leadership, MD Advisors, IP leadershipWhat: Discusses any barriers that will need leadership interventionWhere: Same location Monday thru Friday When: 1300How: Determine plan to resolve
Care Model Redesign
Professional Exchange Report (PER) & review of goals with Patient
Interprofessional Team Care Briefings to discuss
Patient progression
Escalation Rounds to remove barriers to Patient progression
Implement Strategies for Care Progression
Interdisciplinary Patient Assessment: electronic
communication
Team Goals & Recs on Patient communication
board
CMR 2.0: Identified an opportunity …inclusion of other Interprofessional (IP) team members
• Revisited current CMR (nursing focused)• Adopted/adapted standard work for the roles of 6 critical departments
(Care briefings’ participants)• Designed standard work for handoff, care briefings, workflow• Biggest win: Entering and exiting a room standard work
Campus wide Standard WorkEntering and Exiting a Room
Reliable methods/Job aides
Established daily routines
3 Big Initiatives
Care Model Redesign
MemorialCare Hour
Lean Management
System MemorialCare
Hour
Lean Management
System
What is MemorialCare Hour?
Who: Nurse Leaders Interprofessional LeadersWhat: Touch point by leaders with each patient/familyWhere: At patient bedside When: 2-3 pm Why: #1 Impact patient experience
#2 Ensure sustainment of standard work#3 Address any gaps and develop a plan
Impacting the Patient Experience with MemorialCare Hour
3 Big Initiatives
Care Model Redesign
MemorialCare Hour
Lean Management
System
What is a Lean Management System?
• A system that guides and directs the actions and efforts of the team that promotes personal and organizational success
• The goals of a Lean Management System is to*Develop People
*Solve Problems*Improve Performance
Identified Operational Drivers
• Patient Experience– Achieve a 5 star rating from CMS– Achieve top box scores for patient experience in all categories
• Response, Courtesy & Respect, Pain Management, Education
• Patient Safety– Prevent Hospital Acquired Conditions (HAC)
• Falls, CAUTI, CLABSI, VTE, and HAPI, etc.– Maximize pay for performance incentives
• Patient Progression– Reach LOS annual goal
ESP: Experience…Safety…Progression
“ESP” is very descriptive of someone (or a
group) knowing what is going to
happen and when it is going
to happen
Use Lean methods,
mindset, and management
system to predict/affect the
results and outcomes that specific actions will produce.
Ideal Behaviors = Ideal Results
Leader (ALIGN) Manager (ENABLE) Staff (IMPROVE)• Routinely set and share
vision• Model/coach
management • Know if/where we’re
winning or losing today• Identify opportunities to
share/spread learning
• Own unit level goals and outcomes
• Communicate purpose & meaning of systems
• Model/coach staff to discover root cause, find countermeasures, and improve processes
• Respond to real time data• Acknowledge problems for
permanent problem resolution
• Own and operationalize patient plan of care to provide an excellent patient experience
• Use and improve the tools • Measure and monitor process
performance• Identify problems/issues and
offer potential solutions • Adhere to operational
standard work
Leader/Manager (shared) Manager/Staff (shared)• Adhere to leader standard work• Regularly go to gemba to identify & remove
barriers• Recognize and celebrate • Use and improve the management system
• Remove barriers (patient care)• Recognize and celebrate
Roadmap
CMR LMS 1.0 IP CMR LMS 2.0
DesignTest & Adjust
Operate
DesignTest & Adjust
Operate
DesignTest & Adjust
Operate
DesignTest & Adjust
Operate
12 PATIENT CARE UNITS, EMERGENCY and 9 INTEPROFESSIONAL DEPARTMENTS
Cascading Goals and Metric
The Pursuit of Perfect CareLink to Strategic Plan… Cascading Goals and Metrics
CampusService
Line Dept. UnitCNO VAT Nursing Division
ESP Targets
HCAHPS: 75th percentile
top box
HACs: Zero occurrences
Medicare ALOS: 4.5 days (Adult)
Medi-Cal ALOS:6.0 days (Adult)5.0 days (MCH)
3.0 days (Women’s)
How to start?
1. Identify Key Performance Indicators2. Review and analyze your results3. Determine the gap4. Perform Root Cause Analysis to identify what processes impact results 5. Select critical processes
● Measure daily ● Make it visible ● Huddle daily
6. Determine the plan to address the gap in reaching target (plan for today and ideas for tomorrow)
Operational Drivers….Reviewed Current Results
Patient ExperiencePress Ganey Scores
Patient SafetyHospital Acquired Conditions
Patient ProgressionLead Time, ALOS
Control Board (Tier 1)
Department Board (Tier 2)
Process Metrics Roll-up
Result Metrics
Tracking HACs
Service Line Board (Tier 3)Nursing Division Board (Tier 4)
Tier 3 Tier 4
Let’s Practice
PROCESS VS.
RESULT METRICS48
Process versus Result Metric
Discharge within 2 hours after order is written
Process versus Result Metric
Patient Complaints
Process versus Result Metric
# of Unusual Occurrence Reports
Process versus Result Metric
Response Time to Call Button
Process versus Result Metric
Patient Satisfaction Surveys
Process versus Result Metric
Bed Alarm is on for high fall risk patients
Continuous Improvement
Process to calculate # of ideas submitted/ # of ideas implemented throughout the areas
IDEAS SUBMITTED
IDEAS IMPLEMENTED
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
IDEAS
AT WORK, MY OPINION ALWAYS COUNTS!!!
Then what???? ….Leader Standard Work
MemorialCare Hour Control Board Huddles Standard work audits
discipline
How do you know how your area is doing?
Leader Standard Work:Control Board Huddles
Leader Standard WorkKamishibai Boards
Step 1: Pull a card Step 2: Observe all steps, assess and coach
Step 3: Document and display the results…PDSA
Leader Standard Work (Leader’s Routine)
• Leaders are held accountable in performing their standard work
Tier 1- AUMActivity Frequency (minimum) Purpose
DAY
AUM to AUM/RC hand off Daily To share information (as per standard work) to oncoming AUM/RC to ensure a safe and
effective hand off
Care Briefings Daily To cover staff RN for immediate patient need otherwise observe
the process to determine how the unit is operating and provide
resources as needed
MemorialCare Hour DailyPerform assigned zone patient interviews and address any concerns, perform standard work observations, complete audit form and place results on control board as appropriate; engage with staff/families
Control Board Huddle DailyLead huddle (RC to lead when
there is no AUM coverage) adhering to standardized agenda
Continuous Improvement Weekly Triage ideas, assess, assign, account Just Do Its
Standard Work Audits Daily To observe the entire process, evaluate adherence, give
feedback/coach
NIGHT
AUM to AUM/RC hand off Daily To share information (as per standard work) to oncoming AUM/RC to ensure a safe and
effective hand off
MemorialCare Hour (night version) Daily
Perform patient interviews and address any concerns, perform standard work observations, complete audit form and place results on control board as appropriate
Control Board Huddle DailyLead huddle (RC to lead when
there is no AUM coverage) adhering to standardized agenda
Standard Work Audits Daily To observe the entire process, evaluate adherence, give
feedback/coach
Update control board graphs with new graph and place weekly average on Tier 2 board
Weekly (Sunday)
Maintain visual management system
Transformation: Culture Change
“ I feel I am not fully doing my job if I am not checking for a fall risk band and to see if the bed alarm is on when I visit a patient.”
Shanshan SongRegistered Dietician
Transformation: Culture Change
“When I went to Diane (director) with a problem…she would just fix it. Now she coaches me how to solve the problem.”
Penne Baray, RN, Assistant Unit ManagerBirth Care Center
Transformation: Culture Change
“Leader Standard Work has shown me that it is better to flame the embers of ideas and solutions of the front line staff than to try to be a firefighter.”
Mary Margaret Montgomery, PTDirector of Rehab Services
Transformation: Culture Change
“Involving your team empowers all of us together to improve clinically, professionally and personally …..all that benefits the patients and families.”
Kim West, RNDirector of Clinical Operations ICU/CCU
Top 10 Ah Ha’s
#10 Don’t limit the ability to standardize with “we are different” #9 Starting small is essential to going big #8 Be sure to include the entire Interprofessional team #7 Don’t depend on local heroes; make it a team effort #6 Don’t expect this to be perfect; be patient with the process #5 Leadership must drive the efforts and role model the behavior#4 This takes discipline#3 Just because standard work is created, doesn’t mean it is being followed#2 Everyone must know the Why and What’s In It for Me#1 Staff must understand the value in everything they do and how it impacts
patient care… it is essential to always keep the patient/family in the center
Next steps
• Continue spread CMR/LMS• Upcoming LMS (Perioperative Services, Miller Children’s
Out-Patient Specialty Care)• MemorialCare Experience (Simply Better)
Simply Better
Questions: The Faces Behind the Work…
