Quality Improvement Project

Control Report Out

Prince County Hospital

Surgery Floor Lean Project

July 10th, 2014

Define

Health PEI’s ELT ( Executive Leadership Team ) identified the service

areas throughout the province for the LEAN projects. The primary

focus was to facilitate an overall decreased LOS (length of stay).

HPEI Surgery PCH Surgery

Staffed Beds Occ Rate 82.0% 93.4%

Budgeted Beds 56.0 20.0

Average Daily Census 44.1 18.7

ALC Avg Pts Per Day 0.8 0.4

% Pts ALC 1.9% 2.0%

Daily Num Pts Medically Discharged 0.7 0.4

ALOS (Acute Days) 6.0 6.7

Total Length of Stay (Days) 6.2 7.1

ELOS (Days) 4.8 5.5

Re-Admit Rate <= 7 Days 2.5% 2.3%

Re-Admit Rate 8 to 28 Days 3.7% 3.4%

Intra Transfer Pts Per Day 1.5 0.5

Pts Moved Per Day 0.8 0.5

CI ( Level 2 - 5) (3 mth rolling average) 9.7 3.7

Avg Med Error Rate (# per month) 0.0 0.0

Pd Hours As % Of Budget Hrs 130.70 137.06

Define

• Problem Statement

Our current process lacks communication, creates duplication, and

has undefined roles which results in staff dissatisfaction as identified

by feelings of being unsupported.

We want to foster a culture of a patient focused, multidisciplinary,

collaborative care team which will result in timely referral and

discharge processes.

Measure

• The time physio referral is sent to the time the assessment is

document.

• Measure the amount of times the ward clerk is required to do duties

off the unit. (ie portering, printer, stores etc.)

• Number of Times required to answer the phone at the nursing

station

• Time from call requesting bed until time the bed is ready for

patient. Including whether completed by bed control or unit

environmental services staff.

• The amount of time Clinical leader spends reviewing and

completing narcotic sheets

Measure

• Track the times of Physician arrival on the unit.

• Track the times the discharges are written, time patient left unit,

what service the patient was under.

• Track the time spent clarify orders

• Tracking the amount of time spent reporting shift to shift including

the hands off and reports between disciplines during the shift.

• Time spent updating report sheet

• Track the documentation on the admission history that populates

to the discharge summary

Analyze

There is an average time from physio consult to documentation of 22

hours; this is within the standard, but may be a gap for other health

care providers.

Overall ward clerks and nurses daily average of time spent off the unit

is not as much as previously reported however there is certainly

fluctuations related to demands on particular days that can limit patient

care hours.

Phone calls at the nurses station consistently show higher numbers of

calls from other nursing units as opposed to families which was

previously thought. Further data analysis might provide more insight

into the reason for other nursing units/supervisor calls.

Analyze

The bed control staff are completing the beds when requested taking an

average time of 51 minutes to complete. Housekeeping provided

additional support when isolation rooms were identified.

On average the clinical leader spends 5 minutes a day reviewing narcotic

sheets. Note that time fluctuates with her available time.

Physician arrival time on the unit occurs most often in the am with only a

few physicians arriving in the afternoon. Discharge order times do not

seem to be impacted as the majority of discharge orders are written early

in the day.

Overall, discharged patients left in a timely manner leaving 99 minutes

after discharge order was written.

Analyze

The amount of time clarifying physician orders was not noted to

consume much nursing time as previously thought.

The amount of time reporting seems to take up nurse patient hours with

the huddles from team members to team leaders taking the most time.

Updating the report sheet is another component (tool) of the report

process with not all team members using the tool which takes up both

nursing and ward clerk time. The service delivery (surgical services )

leads to more rapid turnover and therefore frequent updating.

The admissions are mainly completed by the floor staff as opposed to

float staff. Elements helpful for discharge planning on the admission

assessment and history form are not completed. The discharge

planning/education is poorly documented.

Improve

PDSA 1

Description: Following the physio assessment, Physio does an

orderable for nursing when applicable to communicate plan of

care. (ie. ambulation order).

• Following seeing the patient the physiotherapist will initial and

check the unit boards indicating the patient was assessed by PT.

Date Implemented: June 16th, 2014

Improve

PDSA 2

Description: Revise reporting process to do paper reports rather

than taped. The written report created will provide a concise

standardized process to communicate necessary patient

information for direct patient care from shift to shift, as well as

act as a working reference tool to replace the current report

sheet.

Date Implemented: June 16th, 2014

Improve

PDSA 3

Description: Assess and streamline documentation to ensure it

meets patients’ care needs.

• Physio and nursing will use the ongoing discharge planning form

to document the functional and home environment assessments.

Date Implemented: June 16, 2014

Improve

PDSA 4

Description: Improve the Documentation of Patient Teaching

Date Implemented: June 16th, 2014

Improve

Aim statements:

80% of patients will have documented teaching prior to

discharge.

Reduce overall reporting time for test team by 50% for 24 hours.

80% of functional and home environment assessments will have

more than two data elements documented within 24 hours of

admission.

90% of all patients will have ambulation orders (when

appropriate) entered by physio following assessment of patient.

Analyze

Avg = 37:30

Time from physio referral to completion of documentation

Analyze% of ambulation orders placed when appropriate

Patients with Ambulation Orders

100%

88.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Pts with PT Consult % Pts with Ambulation Orders

% o

f P

ati

en

ts

Analyze

Report Times - Green Team

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57

1:04

1:12

1 2 3 4 5 6 7 8 9

Avera

ge T

ime

T2Average T1 Average

1 Night RN report prep

2 Day Staff receiving report

3 Team members to Team leader

4 Clinical Leader to Team leaders

5 Evening Staff receiving report

6 Day RN report sheet prep

7 Night Staff receive report

8 Team members to Team leader (N)

9 Team leader to 2300 staff

T2 Average Total/Day = 3:15

Average report times for Green Team

Analyze

Report Times - Blue Team

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57

1:04

1 2 3 4 5 6 7 8 9

Avera

ge T

ime

T2 Average T1 Average

1 Night RN report prep

2 Day Staff receiving report

3 Team members to Team leader

4 Clinical Leader to Team leaders

5 Evening Staff receiving report

6 Day RN report sheet prep

7 Night Staff receive report

8 Team members to Team leader (N)

9 Team leader to 2300 staff

T2 Average Total/Day = 3:35

Average report times for Blue Team

Analyze

Report Sheet Prep Times - Night RN

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55

2:09

6/16

/201

4

6/17

/201

4

6/18

/201

4

6/19

/201

4

6/20

/201

4

6/21

/201

4

6/22

/201

4

6/23

/201

4

6/24

/201

4

6/25

/201

4

6/26

/201

4

6/27

/201

4

6/28

/201

4

6/29

/201

4

6/30

/201

4

Tim

e E

ach

Day

Night RN report prep - Green

Night RN report prep - Blue

Range Green = :30 - 2:00

Blue = :15 - 2:00

Report sheet prep times for Night RNs

Analyze

Report Sheet Prep Times - Day RN

0:00

0:28

0:57

1:26

1:55

2:24

2:52

6/16

/201

4

6/17

/201

4

6/18

/201

4

6/19

/201

4

6/20

/201

4

6/21

/201

4

6/22

/201

4

6/23

/201

4

6/24

/201

4

6/25

/201

4

6/26

/201

4

6/27

/201

4

6/28

/201

4

6/29

/201

4

6/30

/201

4

Tim

e E

ach

Day

Day RN report sheet prep - Green

Day RN report sheet prep - Blue

RangeGreen = :25 - 2:00

Blue = :10 - 2:25

Report sheet prep times for Day RNs

Analyze

Admission & Discharge Tasks

97%

60%

20%

11%

3%0%

93%

59%

86%

73%

28%24%

0%

20%

40%

60%

80%

100%D

isch

arg

e s

um

ma

ry

D/C

tea

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g/in

stru

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ns

(da

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f D/C

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Ho

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Fu

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Pa

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(pri

or

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/C)

D/C

pla

nn

ing

ass

ess

% o

f P

ati

en

ts

Time 1

Time 2

% Completion of Admission and Discharge tasks

Improve

Aim statement:

• 80% of patients will have documented teaching prior to

discharge.

28% of patients received teaching prior to discharge which was

an improvement from the previous measurement of 3%.

• Reduce overall reporting time for test team by 50% for 24 hours.

• Both teams tested written and bedside reporting. No

improvement in time lines as numerous issues being worked

through.

Aim statement:

• 80% of functional and home environment assessments will have

more than two data elements documented within 24 hours of

admission.

• 86% of the patients have a documented home environment

while 76% have a documented functional assessment.

• 90% of all patients will have ambulation orders (when

appropriate) entered by physio following assessment of patient.

• 89% of appropriate patients had ambulation orders.

Improve

ImproveStaff comments and customer feedback on the improvements

Ambulation orders from PT are valuable for nursing staff

Physio and other Allied Health staff value Discharge planning information; its also

useful for nursing on multidisciplinary rounds

Informal survey showed that patients and families feel positive about bedside

rounding; it helps them know the faces attached to the names on the bedside board

It is helpful to have both reports completed by 0800

Some staff struggled and gave negative feedback about the new reporting

format/process

Written reports are a fundamental change; it takes time to get used to such a big

change. Report completion is improving as staff become more familiar

Clinical lead values face-to-face time with patients

ControlWhat controls have we put in place to ensure that performance

does not lapse?

Icon taken off ‘downtime’ computer; staff will not be able to document

there in error (IT, Melissa)

Ambulation orders will become standard for appropriate patients

(Angela)

Duplicate or additional report sheets will be removed (Lisa, Melissa

and WCs)

Storage room has been organized, standardized and colour-coded to

reduce risk and save staff time (Lela/WCs, Cheryl)

Printer/fax machine is better placed for staff use and efficiency

ControlWhat controls have we put in place to ensure that performance

does not lapse?

Periodic chart audit of documentation (home environment, functional

assessment, patient teaching) (Lisa and Melissa)

Ongoing education, communication and demonstration to take place

around written report process; using emails, verbal and written

memos/posts (Melissa and SWAT team members)

Training and/or demonstration for nursing staff on how to conduct

bedside rounds; tip sheet is developed (Melissa)

Provide training on documentation and expectations for ward clerk

role (Lela, Pam)

Sustaining MeasuresWhat data should be looked at on an ongoing basis? (6 data points)

Physio

Ambulation orders (6 x once a month); snapshot of % of appropriate patients with

these (second Thu of month)

Documentation

Chart audits (3 x bi-weekly, 3 x monthly) of home assessment, functional

assessment and patient teaching); (second Thu of month)

Home environment/functional assessment require 2 data elements within 24 hrs

Ensure different teams are audited

Snapshot of all patients in surgery beds

Reporting

Measure report time (for one day-24 hours) x 6 months (second Thu of month)

Lessons LearnedWhat were some of the key things we learned about quality

improvement while doing this project?

Communication is challenging with 24/7 staff

Project and PDSA cycle timelines are tight/challenging; need to be attentive

and available to project needs

Unit leadership team collaborated and communicated well amongst each

other

Inclusion of other services (Physio and Environmental Services) was a benefit

to the team and the project

Good planning and communication to impacted services/areas around the

changes we are making is important (i.e. IT, Telecommunications, Materials

Management)

Identifying and addressing staff concerns is important

Spread PlanHow will we communicate and share our project?

The project is a standing agenda item at Nursing Advisory and Nurse Managers

meetings

Our sponsor/CAO continues to update at Medical staff meetings

Staff on Restorative unit are requesting written reporting and bedside rounds

(starting Monday!!)

ICU will be standardizing their Supply Room

ICU also propose beginning daily multi-disciplinary rounds (i.e. Pharmacy, PT,

RT, Nurse Supervisors), and moving to standardized written/verbal reporting

(away from taped report)

Physio will spread use of Ambulation Orders to all appropriate patients admitted

to PCH

Project team will attend Celebration Day

Next Steps

What is next QI project, next steps or next place the project is

spreading?

Train floats, nursing supervisors and new staff on the written report and rounding

processes

Collaborate with CIS in developing electronic reporting tool

Communicate with union around resolving staff concerns

Identify and resolve individual issues around written reporting process

Invite staff to a meeting/discussion

Move forward with getting rid of the kardex on Surgery unit

Present staff with alternate options for getting kardex information

Supply room will receive ongoing reorganization/improvement in collaboration with

Material Management

The Team!

The Team Mascot!