An An iterative qu quality impr provement pr process to im - - PowerPoint PPT Presentation

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An An iterative qu quality impr provement pr process to im improve pe pedi diatric hospi pital di discharge efficiency

Michelle Hamline, MD, PhD Saturday, June 23, 2018 AcademyHealth Child Health Services Research Interest Group

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Di Disclosure St Statement

• Dr. Hamline has documented that she has nothing to disclose.

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5yo girl with cerebral palsy and seizure disorder, presenting with asthma exacerbation

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Ma Maria’s dis ischarge ne needs…

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AI AIM:

To improve discharge efficiency for children hospitalized on the pediatric inpatient ward.

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Ba Balancing.

Child HCAHPs survey Readmission rates ED revisit rates

Ou Outcome.

Discharge before noon Length of stay index

Pr Proce cess.

Discharge orders before 10am

ME MEASURES:

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Initial planning:

• Multidisciplinary team
• Value stream mapping
• Root cause analysis
• Benefit-effort analysis

OV OVERV RVIEW OF OF PDSA CY CYCL CLES

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Plan Do Study Act

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Plan Do Study Act

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Plan Do Study Act Interventions: 1 Altered physician rounding process 2 Discharge planning checklist 3 Hospitalist and resident education

1 2 3

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Pe Pediatric c Di Disch charge Team Team

• Director of Patient Care Services
• Nurse Manager
• Discharge Planner
• Social Worker
• Pharmacist
• Hospitalist
• Resident
• Performance Excellence

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Val Value ue stream am map apping ng de defines the cu current and desired future proce cess

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La Lack ck of transpo portation and d medi dica cations ac account

• unt for
• r >50% of
• f di

disch charge de delays

10 20 30 40 50 60 70 80 90 100 5 10 15 20 25 30 35 Transportation Medications Unspecified Consults Nurse coordinator Parent Nursing Radiology Supplies Cumulative Percentage of Delays (left to right) Percentage of Discharge Delays

Reasons for patient discharge delays

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Di Disch charge In Interventions

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Plan Do Study Act

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Di Disch charge In Interventions

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Plan Do Study Act

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Di Disch charge In Interventions

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Plan Do Study Act

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20 40 60 80 100 120 140 160 180 200 J u l

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Patient Discharge Count

Number of Patient Discharges by Month

Di Disch charges vary over time and d by by season

BASELINE INTERVENTION 3 1 2

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Avg=13.2 UCL=23.1 LCL=3.3 5 10 15 20 25 30 35 40 45 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 Percentage of patients with discharge orders by 10am Month-Year

U Chart for Patients with Discharge Orders by 10am Over Time

s Limits based on subgroups Jul-15 to Nov-16 Inspection Unit = 100

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In Intervention improved orders by 10am

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Avg=13.9 UCL=24 LCL=3.7 5 10 15 20 25 30 35 40 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 Percentage patients discharged by noon Month-Year

U-Chart for Patients Discharged by Noon Over Time

s Limits based on subgroups Jul-15 to Nov-16 Inspection Unit = 100

In Intervention improved discharge by noon

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In Intervention improved discharge by noon

5 10 15 20 25 30 35 40 Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

Monthly Percentage of Discharged Patients Discharged by Noon

Percentage of Patients Discharged by Noon by Year

2017 (Intervention) 2016 (Baseline)

3 1 2

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No No statistically significant difference in...

• Length of stay index
• Child HCAHPs survey
• Readmission rates
• ED revisit rates

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Co Conclusion:

An iterative quality improvement process involving implementation of a discharge bundle improves discharge efficiency without affecting patient experience or subsequent hospital utilization.

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Fu Future studies:

• Work on sustainability
• Medication fills
• Extend to other services/units

Li Limitations

• Limited sample size
• Generalizability

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Ack Acknowledgments

Mentors: Ulfat Shaikh, MD, MPH, MS Su-Ting Li, MD, MPH Patrick Romano, MD, MPH UC Davis Department of Pediatrics Quality, Safety, and Comparative Effectiveness Research Training Program (HRSA T32HP30037) Mentored Clinical Research Training Program (NIH UL1TR001860) Discharge quality improvement team: Jennifer Rosenthal, MD, MAS Scott Warren Judie Boehmer, RN, MN, NEA-BC, FABC Angie Marin, RNC, MSN Shirley Shingara, RNC, BSN D’Anne Neal, RN, BSN Deann Clark, LCSW Andrew Lee, PharmD Zack Chaffin, MD

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Thank Thank you!

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