TIMELY REFERRALS TO UWOPO-PDSA THINKING

Theda Clark Medical Center Intensive Care Unit

Why did we start a PDSA? During our monthly ICU leadership meetings we

evaluate our UWOPO dashboard Starting in June 2011, we began to separate ICU and

ER data for Theda Clark Medical Center, to understand our opportunities

When the numbers were separated we saw an opportunity for the ICU

Over the next few months we began to collect our background/current state data and documented this in our standard PDSA format

By using the PDSA format we are able to maintain focus on the real problems, focus on working one solution at a time, study our experiments and act if we are not seeing the anticipated outcomes

What did our current state show? Problem Statement: Within the TC ICU, when ICU patients

meet UWOPO clinical triggers staff are calling statline within one hour 62% of the time from January-Sept 2011, potentially missing donation opportunities, delaying UWOPO analysis for appropriate candidates and increased family dissatisfaction with donation process.

Average call time 20.6 hours. Only 4 out of 16 late calls met triggers at time of admission to the ICU.

Ideal State: The TC ICU staff will be timely on 100% of all calls to UWOPO within one hour of ICU patients meeting UWOPO clinical triggers.  

Organizational Tie: By increasing timeliness of calls made to UPOPO we will impact customer satisfaction with our patient’s families and UWOPO by increasing the quality of time and increasing the turnaround time to a decision.

Next Steps Through process observation, process flow mapping, staff

interviews, 5 whys we were able to understand our problems, root cause and potential solution

Experiments tried and outcomes

-11/16 Sam Taylor from UWOPO presented at ICU staff meeting refresher on UWOPO clinical triggers (small staff attendance, but communicated in weekly email update)

-11/24 all staff given updated UWOPO badge backers with clinical trigger information

-11/24 UWOPO clinical trigger reminders posted in all nursing pods and workstations

-1/6/2012 twice daily tracking of all ICU patients to determine those meeting clinical triggers implemented to be completed by resource RN

-October timely referrals at 75% for all ICU patients

-November timely referrals at 50% for all ICU patients

-December timely referrals at 100% for all ICU patients

-January timely referrals at 100% for all ICU patients

Experiments Outcomes to date

Why do we keep doing this work? Organ donation is a key driver for our business

line This work has engaged staff in process

improvement Our unrelenting drive for perfection uncovered

more opportunities than we first considered By using a consistent format and process, you

are able to prove you have a problem and maintain focus on solving that problem

PDSA work is a significant component of the ThedaCare Improvement System, and integrated into our culture of continuous learning