Saving Time, Saving Money and Increasing

Satisfaction

Tammy Smith, MSN, RNC-obRenece Waller-Wise, MSN, CNS, CLC, LCCE, CNL

Creating an Obstetric Preadmission and Discharge Clinic

Creating an Obstetric Preadmission and Discharge Clinic

Staff of the Family Birth Center at Southeast Alabama Medical Center (SAMC) in Dothan, AL, reviewed the literature to study best practice in patient education, Centering Pregnancy® and promoting family-centered care environments. As a result, we developed an obstetric preadmission and discharge clinic. The focus of the preadmission clinic and group-format discharge class bought patients into a setting where consistent educa-tion is completed in a relaxed and controlled environment. The overall experience results in positive outcomes for patients and the hospital. This is the story of how we did it.

About Our FacilitySAMC is a 420-bed not-for-profit regional referral center serv-ing 600,000 residents in our geographic area. The Family Birth Center at SAMC offers a state-of-the-art facility with a family-centered approach to care, where more than 1,700 newborns are born annually in 27 labor-delivery-recovery-postpartum (LDRP) rooms. The Family Birth Center includes a Special Care Nursery (Level II) and a five-bed Maternity Evaluation (triage) unit. The primary language of the patients giving birth is English, with approximately 5 percent speaking Spanish as their primary language. Most recent data show a payer mix of 39.8 percent from private insurance. Medicaid payment ac-counts for 57.7 percent, including payments from Florida and

Georgia. One percent of payment comes from Medicare, and 1.5 percent is private pay.

A review of the statistics from the childbirth education de-partment revealed a declining trend in childbirth class attend-ance. Fewer patients were attending prenatal classes, averaging only 19 percent of the primapara patient population. The goal of the department was to have 50 percent of first-time mothers

attend class. Sadly, we discovered that we were not unique, with only one-third of expectant parents participating in classes na-tionwide (Berman, 2006).

Changes in hospital reimbursement from insurance com-panies had placed a greater emphasis on outcome measures. We identified that many of these measures could be achieved through improvements to patient education. There was greater recognition of the importance of health education and its abili-ty to assist in the economic goal of reducing high costs in health care. We knew that there are costs associated with developing any educational program, but we believed the cost benefit oc-curs when patient satisfaction increases and a lifelong relation-ship is established. To control costs and to realize cost savings, cost benefits or cost recovery, hospitals must develop ways to deliver patient education more economically (Bastable, 2006). Thus, the staff of the Family Birth Center at SAMC began with an original plan related to the educational needs of our patients. We reviewed best practices and evidence-based literature in an attempt to draw conclusions regarding our current practice, so that changes that could be made. A summary of the literature review follows.

Reviewing the LiteratureAs far back as 1993, the Joint Commission recognized the im-portance of patient education by nurses and began establish-ing nursing standards for patient education. Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered. Providers must also consider the literacy level, education level and language skills of every patient during the education process. Educating the patient will increase the competence and the ability for patients to man-age their care independently. There are many benefits to patient education (see Box 1). When educating a pregnant woman, in-cluding her significant other and/or family can build a larger support system for her, and motivate all involved to promote learning (Bastable, 2006).

One research study we reviewed presented information on a new model of prenatal care and education. This model was based on a client-centered focus and was designed to empower the pregnant woman. This approach used group discussions to augment prenatal care during the final months of pregnancy and early months of postpartum. Group sessions are conducted in a circle to promote trust and authenticity. This circle sup-ports socialization and moves the leader into the group as a member instead of authority figure. Participants socialize and enjoy healthful snacks while learning important information about caring for themselves and their newborns. This model of care has a positive outcome on pregnancy because of the posi-tive influences that social support systems have for the expect-ing mother (Reid, 2007).

Nurses often have insufficient time before discharge to fully address the concerns of new mothers and the potential prob-

120 © 2011, AWHONN http://nwh.awhonn.org

Tammy Smith, MSN, RNC-OB, is the director of the Women’s Center at Southeast Alabama Medical Center in Dothan, AL; Renece Waller-Wise, MSN, CNS, CLC, LCCE, CNL, is a licensed perinatal clinical nurse specialist at Southeast Alabama Medical Center and an adjunct faculty member at Troy University in Troy, AL. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: renecew@hotmail.com.

DOI: 10.1111/j.1751-486X.2011.01620.x

• Staff at the Family Birth Center realized that their preadmission and dis-charge processes could be improved.

• Collaboration among a variety of departments ensured successful change.

• Streamlined processes have resulted in increased patient and provider satisfaction and cost savings.

Bottom Line

April May 2011 Nursing for Women’s Health 121

lems that can occur after discharge. For new parents, the post-partum period can be emotional and is often a time of stress, change and sometimes crises. There is research that attempts to determine what learning topics are the most important to mothers. Studies indicate that the most important teaching pri-orities for postpartum mothers are related to postpartum com-plications and newborn care, with feeding the baby at the top of the list (Birk, 1996; Bowman, 2005).

According to Todd (2004), a needs assessment should be conducted when initiating any education of new mothers. Asking questions that can determine the most important edu-cational needs, as well as evaluating the patient’s pain and emo-tional status, will help determine if learning can occur. It will also help establish a bond between the mother and the caregiv-er. Todd also explains that it’s important to educate members of the patient’s support system, as well.

Another study we reviewed focused on the benefits of group classes during the postpartum period and discusses the importance of empowerment. The Nursing Theory Workgroup (1990) proposed broadly that empowerment should include the practice of nurses assisting clients to recognize their own strengths, make their own decisions and be independent and self-reliant (Aston, 2002).

Finally, today the care of the childbearing family requires the provision of information and support within the constraints of cost containment and shortened length of stay while meeting the needs of culturally diverse families. Declercq, Sakala, Corry, and Applebaum (2007) conducted the second national survey

of women’s childbearing experience. In light of these survey results, the reality of decreased hospital stays for postpartum families means it’s increasingly important that an educational plan including nontraditional approaches be tailored to meet the specific needs of each family.

Processes Prior to ChangeAlthough the labor experience is an exciting time for families, it can be a difficult time as well. The response to pain as well as trying to care for a newborn can be overwhelming. This re-action can inhibit the ability to learn and retain information taught during the intrapartum and postpartum course. Patient satisfaction surveys at our hospital revealed a need to improve the admission, discharge and teaching methods. To identify ar-eas in which patients perceived a need for improvement, we reviewed the Press Ganey database to look at trends in patient satisfaction ratings. Patients reported dissatisfaction with the admission process. We reviewed specific questions from the Press Ganey Survey related to the speed of admission, cour-tesy of person admitting, preadmission process, explanations of test and treatments and information provided to family related

Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered

box 1 Benefits of Patient Education

• Increasespatientsatisfaction

• Improvesqualityoflife

• Improvescontinuityofcare

• Decreasespatientanxiety

• Effectivelyreducespatientcomplicationsandincidenceofdisease

• Promotestheadherencetotreatmentplans

• Energizesandempowerspatientstobecomeactivelyinvolvedintheirplanofcare

122 Nursing for Women’s Health Volume 15 Issue 2

quality work in a timely manner. Many nurses experienced de-lays in charting due to the increased amount of tasks involved with discharging a mother-baby dyad. Much of the education that could have been initiated on admission was not started un-til discharge. This bottlenecking resulted in an increase in over-time hours due to the nurse staying after the shift to complete charting. The unit’s overtime percentage for salary was above the target. In light of these issues, members of the unit began to research information to find ways to improve each of these areas in addition to our education changes.

The process previously in place required patients scheduled for cesarean surgical deliveries to attend a preanesthesia clinic scheduled through the surgery department. During this ap-pointment preanesthesia nursing assessment and surgical con-sent forms were initiated before the admission day of surgery. Upon admission to the birthing unit, the labor nurse completed a seemingly duplicate nursing admission assessment and unit-specific consent forms, drew blood for lab work and began the initial intrapartum education.

Planning and Preparing for ChangeAfter our literature review, which took approximately 3 months to complete, we found that evidence-based practice suggested that improvements could be made to the admission process and teaching methods. A practice change was evaluated to stream-line the admission process and individualize teaching methods for patients scheduled for induction of labor and for cesarean

to conditions and treatments. We also reviewed Press Ganey questions related to discharge. Specifically we looked at extent they felt ready for discharge, speed of discharge, instructions for care at home and explanation concerning baby needs (see Box 2). Due to the low patient satisfaction ratings in this area, we placed a particular focus on this in our work.

We began to review our processes of education from admis-sion to discharge and discovered that there were more processes that could be included in our project. Physicians complained that there was a delay in preparing inductions and a delay in surgery start times in the morning upon the patient’s arrival. Inconsistencies were found in the patient registration process. Some patients were registered in the emergency room while others were admitted in the birthing unit. The combined admis-sion history and physical exam, consenting process, blood work and education averaged approximately 1 hour or more to com-plete. This delayed the nurse’s ability to initiate the induction of labor or prepare the patient for surgery in a timely manner. This limited amount of time also burdened the nurse to complete a large amount of work in a very short time frame. Nurses who worked the night shift often had to stay past the end of their shifts to complete work due to the patient’s arrival time. The nurse was not able to complete adequate education before the start of the patient’s labor. The information was typically rushed and the patients were not given time to ask questions.

The birthing unit’s employee satisfaction surveys revealed that nurses were dissatisfied due to the inability to complete

box 2 Press Ganey™ Patient Satisfaction Scores

Admission Before Implementation After Implementation (Year to Date 2005) (1 Year Later 2006)

(mean scores) 85.7 92.9

Speed of admission 83.9 91.1 Courtesy of person admitting 92.9 95.8 Preadmission process 80.0 92.2 Explanations happen during tests and treatment 90.9 91.7 Info family re: condition/treatment 87.5 95.1

Discharge Before Implementation After Implementation

(mean scores) 86.2 90.0

Extent felt ready for discharge 86.2 93.7 Speed of discharge 71.4 83.2 Instructions care at home 93.7 94.6 Explanation concerning baby care 92.1 94.6

April May 2011 Nursing for Women’s Health 123

sion. This process also included a protocol for patients who re-fused to wear an armband until admission and for those who returned for admission without the armband.

Potential time savings were identified at this point with respect to how blood work was completed by the laboratory. Under the old system, all lab work was completed as a “stat” specimen on the day of admission so that results would be available before the start of the procedure. Under the new sys-tem lab work would be run as “routine” during the preadmit visit. Serendipitously, this allowed the laboratory department to focus on more critical lab draws and resulting during the high volume times of early morning.

PreanesthesiaA meeting was then held with the existing preanesthesia clinic and we determined which parts of the patient record were du-plicated. It was decided that all surgery paperwork normally completed at the preanesthesia clinic would be completed during the new obstetric preadmission appointment. For con-venience of the patient, the obstetric preadmission clinic would now be the only appointment the patient would have to attend.

Meetings were held with anesthesia personnel, social work-ers and case management, along with lactation services. These meetings involved a mechanism to trigger consults with these departments when patient problems were identified during the preadmission process. This would prevent late discovery of a patient’s complications. For example, identification of a patient who may not be a candidate for an epidural or may need as-sistance for an early detection of a breastfeeding complication might be discovered during the preadmission visit. A process was established to refer patients who warrant consults with these issues.

Other DepartmentsMeetings were held with the printing department to develop appointment cards with instructions on appointment date and time as well as directions to the clinic. A process for scheduling of patient appointments for the clinic and utilization of the ap-pointment card was then determined.

Networking with the systems manager for the computer-ized labor documentation system assisted us in the process for documentation. A new screen in the documentation system was then created to use during our preadmission appointment. This screen would include the nursing assessment, lab work, consent information and all education to be taught during the

deliveries. Group teaching was evaluated to streamline dis-charge teaching for postpartum mothers and establish a com-fortable supportive environment more conducive to learning.

At this point, the process of establishing a preadmission clinic and discharge class for the birthing unit began. Prepa-ration to initiate the preadmission clinic took place 6 months before the opening of the clinic, during which time meetings were held with ancillary departments to revise processes and implement the new practice change. Involvement of all depart-ments in changing practices ensured the success of the project.

RegistrationOne goal was to streamline the registration process; therefore, meetings were held with this department. Previously, the pa-tient presented in one area of the hospital to be registered and was taken to another area for treatment. Many times patients were lost within the facility. Changes to the registration pro-cess included converting an existing unit secretary position to a registration representative who would register the patients directly on the unit. This person would be able to issue a pre-registration number for the mother and the newborn as well as have the patient sign forms to initiate treatment for both mother and newborn during her appointment time. The im-plementation of the registration representative also allowed insurance information and billing to be obtained during the preadmission process. Patients requiring precertifications for insurance, copayments and filing of Medicaid letters could be handled during this process.

LaboratoryLaboratory was the second department involved in the prac-tice change. Previously, labs were drawn either in preanesthesia clinic or on admission, which slowed the process of preparing the patient for induction of labor and/or surgery. Meetings with laboratory took place to determine the feasibility of drawing and running lab samples on Friday for a scheduled surgery on Monday. These meetings included consent from all obstetri-cians, anesthesiologists and pathologists to complete a com-plete blood count as well as a Type and Screen for surgery for these patients in advance of induction or surgery date.

Plans also involved establishing a mechanism for blood samples to be obtained and analyzed in this new outpatient set-ting. This included a mechanism for identifying the patient at the time of the preadmission appointment with an armband that would remain in place until and including hospital admis-

Involvement of all departments in changing practices ensured the success of the project

124 Nursing for Women’s Health Volume 15 Issue 2

a certified car seat technician discusses the importance of car seat safety and schedules appointments to install the car seat for the families. The discharge class also includes important follow-up instructions for new parents for both the baby and the mother. Using hands-on demonstration, parents learned to care properly for circumcisions and umbilical cords. The par-ents are given information about the class starting in childbirth education classes and also the preadmit clinic. They also are receiving information on admission to the unit to encourage attendance any day until discharge.

Evaluating the ResultsOverall, the implementation of the process change has affected the unit and organization positively. Before the initiation of the preadmission clinic, average patient admission to initiation of oxytocin averaged 1.5 hours for our induction of labor patients. After 1 year, among patients who attended the preadmission clinic, average admission time to initiation of oxytocin has decreased to 30 minutes. This change pleased not only our pa-tients (see Box 3 for patient comments), but also our physicians, midwives, nurses and support staff. The reduction in admission time and improvement in patient education have allowed for more time for the admission nurse to interact with the patient, outside of completing paperwork. Marie, a labor specialist on the unit, said the new process has helped tremendously with time management. “Now I don’t need to spend 1 or 2 hours completing paperwork before starting the induction,” she said.

After initiation of the preadmission clinic and discharge class, patient satisfaction ratings improved for both admissions and discharge based on the Press Ganey database for specific

clinic visit. The forms could be printed and placed with the mother’s and baby’s chart for the labor nurse to view on admis-sion. On admission, the labor nurse would only need to com-plete the physical assessment, initiate intravenous access and initiate fetal monitoring.

Childbirth EducationConferences were then conducted with the childbirth educa-tion department to involve our educators in determining what patient education was to be completed and what teaching methods were to be used during the preadmission appoint-ment. Ultimately, it was decided that the preadmission clinic would be staffed from the childbirth education department, and a position was created for a designated nurse. This posi-tion was created by moving a staff nurse full-time equivalent from the birthing unit to the childbirth education department. This decision was based on the best practice idea that offering consistent teaching methods would improve the overall patient experience and learning atmosphere. Once this process was es-tablished, educational meetings took place with all staff located on the unit, as well as admitting obstetrician offices, to inform and educate these groups as to the change in process for pa-tients with scheduled procedures.

Implementing ChangeThe first phase of this process change—the establishment of the preadmission clinic—was in place for approximately 6 months while we evaluated the flow of the process. Minor changes were made to the process, including the physical location of the clinic. This 6-month time frame also allowed the Family Birth Center staff and ancillary services to become accustomed to the new process before initiating the next phase of the change.

The second phase of the process change was to implement a class setting in which the same preadmit nurse could complete appropriate postpartum and newborn care teaching before dis-charge. We then began working on what information should be included in the class, teaching methods used and time frame for the class to occur. A group setting with a circular seating arrangement was decided upon based on the Centering Preg-nancy® approach to promote a comfortable environment that fosters socialization. The class would be called “Mom and Me Tea.” Cookies and tea would be offered to promote a relaxed en-vironment, and it was sometimes referred to by the nickname “Tea and Teach.”

The class was scheduled for 10:30 a.m. each morning before the normal discharge time of families. Multiple teaching meth-ods are used, including videos, handouts and verbal instruc-tion. The fathers and other support persons are encouraged to attend the class to foster support for the new mom, and teach them how to care for the new mother and baby. Education was included to cover basic newborn care as well as danger signs, new mom care and when to call the doctor. During this class,

April May 2011 Nursing for Women’s Health 125

viding individualized one-to-one teaching that is client-centered during our preadmission process has prepared the patient to have a positive labor experience (see Box 3). Providing discharge teach-ing in the group setting fosters relationships and improves the learning experience of the patient and family. Sheila, a mother-baby nurse on the unit, believes that the education is also more consistent, because for the majority of the time the same nurse is providing the instruction day after day. She also said, “I can do other things to prepare the couplet for discharge other than teaching and get the family discharged in a more timely manner.” The process change aligned the unit with the family-centered care approach in which it has based its model of pa-tient care. As an ongoing process, the unit continues to find ways to improve the preadmission clinic and discharge class to support the continuing needs of our patients. NWH

ReferencesAston, M. (2002). Learning to be a normal mother: Empowerment and pedagogy in postpartum classes. Public Health Nursing, 19(4), 284–293.

Bastable, S. B. (2006). Essentials of patient education. Sudbury, MA: Jones and Bartlett.

Berman, R. (2006). Perceived learning needs of minor-ity expectant women and barriers to prenatal educa-tion. Journal of Perinatal Education, 15(2), 36–42.

Birk, D. (1996). Postpartum education: Teaching pri-orities for the primapara. Journal of Perinatal Education, 5(2), 7–12.

Bowman, K. G. (2005). Postpartum learning needs. Journal of Ob-stetric, Gynecologic, & Neonatal Nursing, 34(4), 438–443.

Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2007). Listening to mothers II: Report of the second national U.S. sur-vey of women’s childbearing experiences. Journal of Perinatal Education, 16(4), 9–14.

Nursing Theory Workgroup. (1990). Creating our own conceptual framework: Values and beliefs about public heath nursing in the city of Toronto. Ontario, Canada: City of Toronto Health Depart-ment.

Reid, J. (2007). Centering Pregnancy®: A model for group prenatal care. Nursing for Women’s Health, 11(4), 382–388.

Todd, L. (2004). Three not so easy steps to getting families off to a good start. International Journal of Childbirth Education, 19(3), 24–27.

questions selected. The Press Ganey results for the specific ad-mission questions pertaining to the Family Birth Center before change are listed along with the comparison and improvements to these questions after the process change in Box 2. An over-all rating of the admission process improved from an overall mean score of 85.7 to 92.9 for the selected questions. The same process was repeated for the discharge evaluation. The specific Press Ganey questions revealed the overall discharge rating im-proved from 86.2 to 90 (Box 2).

In addition to improvements in patient satisfaction, the change in the registration process allowed us to handle precer-tifications for insurance, copayments and filing of Medicaid let-ters in a preadmission environment. Within the first year of this change the Family Birth Center captured a total of $27,395 in copayments previously uncollected.

ConclusionThe implementation of the preadmission clinic and discharge class has made a positive impact on patient education. Pro-

box 3 Comments From Patient Surveys

The thing you liked best about the preadmission visit:• “Itwasaverysincereperson-to-personlevel.”

• “Iwasabletohaveallthepaperworkdoneaheadoftime.”

• “Gettingtosignallthepapersbeforehand,andjustfeelingeasierabouttheinduction.”

• “Allinformationcoveredbeforedayofsurgery.”

• “Ididn’thavetoanswerallthequestionsondayoflabor.”

• “ThefactIdidn’thavetodoitallonthesameday.”

General comments: • “Reallylearnedalot,verycomfortableandfriendly

environment.”

• “Veryinformativewithacaringatmosphereandgenuineconcernforthepatient.”

• “Ilikedcomingonedayearlytopostponearrivaltimeondateofsurgeryandeaseofcominginforc-section.”

• “Thepreadmissionprocessmadeiteasierforme.”

The thing you liked least about the preadmission visit:• “Chairwasn’tverycomfortable,butotherthanthatitwas

agreatvisit!”

• “Theepidural/spinalvideo.”

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