IN THIS ISSUE:

Greetings from DHM QI!

Divide Your Writing Into Manageable Tasks P. 1

QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE

Thank You Katie! P. 1 Introducing the APeX discharge guide P. 4 Division Incentive Metrics P. 5 Applying Lean to Transitions in Care P. 2-4

Welcome to the 28th edition of the Quality Post. In this issue, we say goodbye to Katie and all the tremendous work she’s done this year. We also describe our journey to apply Lean to transitions in care. As usual, see the last page for our Division Incentive Metrics!

Thank You Katie, We’ll miss you!

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Monthly Quality Improvement Newsletter FOR THE

Division of Hospital Medicine April 2013 Ÿ Issue 28

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Divide Your Writing Into Manageable Tasks Sometimes the worst part of writing an email, proposal, or pitch is getting started. Get over the hurdle by approaching the project as a series of manageable tasks. Poet, writer, and teacher Betty Sue Flowers envisions the steps as belonging to four different characters in your brain: • Madman. Start by voraciously gathering research and other materials for the project, diligently keeping track of quotations and sources. • Architect. Then organize the madman's raw material into a sensible outline. Distill your ideas into three main propositions. • Carpenter. Following the architect's plan, write as quickly as possible — without worrying about perfecting your prose. • Judge. Lastly edit, polish, and improve the piece. Do this in several distinct passes, each time focusing on only one element of your writing.

Adopting LEAN at UCSF Why Lean?

The Lean Tenets

Lean is a quality improvement method designed to maximize customer (e.g. patient) value while minimizing waste. Simply, lean means creating more value for patients with less wasted time, energy and resources. In our cost-conscious times, Lean represents an attractive way to streamline our processes while improving quality. In an academic hospital setting a lean process can leave more time for other parts of our mission besides patient satisfaction such as education and scholarship.

Value the Patient: Valuing the customer is knowing what the patient is willing to pay for. Map the value stream: The value stream is the sequence of activities required to provide patients with a product or service. Seek out Waste: Look for and eliminate the four areas of waste in processes: Overproduction, Waiting, Transportation, Processing, Inventory, Movement, & Defective Products. Flow the process: Understand what keeps the process from flowing Conduct Kaizen events: Rapid cycle process improvement Create Standardized Work: i.e. best practices. The precise description of each work task specifying task times, cycle time and inventory/parts/people needed to meet demand.

Our Journey with Lean: The UCSF journey with lean began in Pathology & with the Revenue Cycle. The 5 week intensive training and Kaizen process was a success with the participants achieving the goals of increased efficiency & safety of specimen processing in Pathology, and decreased time needed for prior authorizations and the billing cycle.

Our very own Maria Novelero participated and along with others suggested the discharge process as a future “Lean” opportunity. After a successful Transitions of Care Retreat with Medicine, Orthopedics and Pediatrics, the work was ready to begin on 14L with ...

Week 1: Value Stream Mapping The week of value stream mapping involved an intense week of observing and cataloging the steps in a process and the wait times in between. At each step the following times are recorded: Cycle Time: The time it takes to complete the actually work of the process Lead Time: The actual time the process takes including both cycle times and wait times Value Added Ratio: The percent of time that actually has value in the process

 

The Tools of Value Stream Mapping Spaghetti Diagram: Following a nurse for 3 hours

Time Observation forms: from the view of the patient .

.

 

Mapping the Value Stream: From Observations to process

Fact Card

Add in some idea cards...

Idea Card

Value Stream post Brain Storming

The Way Forward The Output: An A3 Team Charter A3-T

Set high standards that focus on successful launch for our

The end result of the Value Stream Mapping is the A3T, or team charter. Key elements of the charter are:

TEAM CHARTER

Date:

15-Feb-13

Reporting Unit: 14 Long & 14 Moffitt

PROBLEM STATEMENT The lead time from arrival on floor to admission complete is 48 minutes with 71% VA activity; however many interventions required for discharge occur at the back end. Currently, inpatient care delivery is highly variable with redundant workflows and non-standard processes. Observations for the "day of stay" show only 7% VA activity. This compromises quality of care and contributes to revenue loss for UCSF. The discharge process's (discharge decision to departure) total lead time is 1667 minutes (15% VA) with unnecessary waste due to lack of coordination, poor planning, and a cumbersome process. Patient access is challenging with long waits for both ED and Transfer Center patients needing to get into the hospital. The current ALOS for the 14-L/14-M Medicine population is 5.91 days.

The Problem Statement The Target Statement & Proposed Actions

throughout the patient's stay.

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Theme: patients returning to the community and make this a top priority

Dedicated discharge team for coordination of discharge; geographic patient assignment for medicine teams; 24 / 7 service delivery – all services including case management; create standard work for key elements of admission (med reconciliation / others), inpatient stay and discharge processes (initiate these as appropriate upon admission); establish afternoon prospective discharge rounds; move MDR to afternoon; standardize MDR Reporting format; iPad (mobile access) to support care teams (especially medicine teams and case managers); care team contact info in APeX (“first call”) is clear, current and accurate; prioritize work based upon pending discharge status; single data source (APeX) to feed multiple tools (grease boards, worksheets, spreadsheets etc.).; “Closed ICU” – one team managing care of those patients (no duplication of care teams); culture change – physicians becoming comfortable discharging when medically stable; 24-hour case manager in ED to prevent admission of patients who do not meet inpatient criteria; discharge holding area; include bedside RN in discharge process; APeX optimization (worksheets, anticipated discharge list, D/C Summary populated and available to all staff prior to patient departure); revamp physician rounds and medicine team's schedule for the day; more proactive education with patients and family / help set expectations for the hospital stay and discharge.

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TARGET STATEMENT (1) Reduce overall LOS for 25% of Medicine patients by 24 hour,s which will create capacity for an additional ~200 patients annually and decrease ALOS from current 5.91 days (14M 5.7 / 14L 6.1) to 5.65 days. (2) Increase the percentage of patients discharged before noon from 10% to 30% by starting discharge activities at the time of arrival to the floor (front-end load). (3) Improve quality as measured by an increase in current HCAHPS scores of the percentage strongly agreeing with "understood purpose of taking medications to 70% (currently 54% for 14L and 47% for 14M) and Press-Ganey scores on the "Instructions given on how to care for yourself at home" question to 50th percentile (currently 35th percentile for 14L and 1st percentile for 14M).

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ACTION ITEM 5S (Sort, simplify, set in order, standardize & sustain) Day of Discharge Plan for Discharge (begins with admission) Initial Assessment Rounding / Communication Tests, Treatments and Consults Daily Schedule ("Patient Itinerary")

RESPONSIBILITY

DUE DATE

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Analysis Communication: Inefficient/poor communication among interdisciplinary teams lead to incomplete preparation of patients for discharge; defects in communication driven by no single source of information; unclear/inaccurate AVS is a HUGE problem with current discharge process, the ability to bypass Admission Tools in APeX leads to problems; underutilization of tools currently limits timely info exchange creates duplication of effort, lack of milestones for discharge triggers; patient education module doesn't support workflows; patients are not always well prepared for discharge; Discharge Navigator is not optimized or used appropriately by many users; lack of computer (and mobile) access impedes workflow. Process: Individual care team schedules are not conducive to timely discharge; scattered patient assignments, assignment and better supply storage, unclear roles, lack of expectation setting with patient / family; med reconciliation is not performed accurately at time of admission, lack of case management level loading / resources, lack of D/C Huddle checklist, lack of real time scheduling leading to excessive wait times for procedures and tests, long waits for transport at time of discharge, too much time spent rounding in ICU; duplication of efforts. CM model does not support mobile workflow in current environment, lack of standard work. Space: Many physical barriers to efficient workflow, especially on 14M, supplies and equipment are not optimally stored for easy access.

CHECK AND ACT Monitor implementation of Kaizen improvements weekly and workshop targets with completion of 30, 60 and 90 day reports as well as daily audits of standard work. Weekly review with executive team. Development of visual workplace and communication vehicles.

Schedule of Kaizen Events

A series of rapid cycle improvements, “Kaizen events” will be taking place over the course of this year. These weeks are designed to implement and fine-tune the changes in the charter.

Week 1: 5s’s: Sort, Set, Shine, Standardize, Sustain (March 17th) Week 2: Day of Discharge (March 29th) Week 3: Discharge begins at admission (June)

Week 4: Initial Assessment Week 5: Rounding & Communication Week 6: Tests, Treatments & Consults Week 7: Patient Daily Schedule

The APeX Discharge Guide is Here! A pdf of discharge best practices is available on our website! If you have an iphone, you can download it as an iBook to save & share with your team.

1. Open attachment

2. Export

3. Open in iBooks

4. Ta da! Forever an iBook

Division Incentive Metric Performance

¤  

Achieve  >60%  full  bundle  compliance  with   Lactate,  Blood  Culture,  Broad  Spectrum   Antibiotics,  and  Fluid  Resuscitation  

Oct   93%  

Sept   76%  

Nov   94%  

Dec   93%  

Sept   71%  

Oct   73%  

40%  

Jan   81%  

Nov   77%  

Feb   86%   FY  2012  HCAHPS   Top  Box  Score:   72%  

î  

Achieve  HCAHPS  Communication  with   Doctors  Top  Box  score  above  80%   August   75%  

FY  2012  Compliance  

Dec   74%  

Jan   67%  

1  of  4   quarters  

Mar   89%   6  of  12   months  

Feb   76%  

100% MD Communication Sum

90% 80%

MD Explaned Understandably Target

70% 60%

CALENDAR OF EVENTS

R ESIDENT QI L UNCHES M&M type format for Quality Cases: April 10 May 15 June 12

50% July Aug Sept Oct Nov Dec Jan n=37 n=51 n=39 n=48 n=36 n=44 n=57

Promote  appropriate  nebulizer  use  and  early   transition  to  MDI;  Reduce  monthly  nebulizer   use  by  15%    (baseline  ~1000  nebs/mo)   July   Aug   Sept   Oct   Nov   1017   680   449   505   496   Achieve  an  average  MD  hand  hygiene  rate  of   >85%  for  Medicine/Hospitalist   Sept   95%  

Oct   97%  

Nov   98%  

Dec   90%  

¤  

FY  2012  Baseline:      

3.5  per   hospitalization  

Dec   815  

¤

Jan   803  

Feb   750  

CY  2012  by  floor:    

88%  

Jan   88%  

2  of  4   quarters  

Feb   98%  

Mar   671  

Mar   100%  

90% 80% 70%

Jun Jul Aug Sept Oct Nov Dec Jan Feb March n=26 n=34 n=41 n=22 n=63 n=51 n=39 n=25 n=44 n=40 Medicine Floor Summary

è  

Respond  to  >80%  of  nurse  queries     Sept   20%  

Oct   88%  

Nov   91%  

Dec   90%  

Target

FY  2012  Baseline:      

No  Data  Available  

Jan   89%  

Feb   85%  

Apr 19 – Cellulitis / Repeat blood cultures May 20 – Perioperative testing

9  of  12   months  

100%

Hospitalist Specialty

R ESIDENT C OST A WARENESS

2  of  4   quarters  

  92%  

F ACULTY QI L UNCHES APRIL: Journey with LEAN MAY: High Value Care JUNE: Division Incentive Metrics