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

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

Di Disclosure St Statement Dr. Hamline has documented that she has nothing to disclose. •

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

Ma Maria’s dis ischarge ne needs…

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

MEASURES: ME Proce Pr cess. Outcome. Ou Ba Balancing. Discharge orders before 10am Discharge before noon Child HCAHPs survey Length of stay index Readmission rates ED revisit rates

OVERV OV RVIEW OF OF PDSA CY CYCL CLES Act Plan Initial planning: 3 -Multidisciplinary team Study Do -Value stream mapping -Root cause analysis Act Plan -Benefit-effort analysis 2 Study Do Act Plan Interventions: 1 Altered physician rounding process 1 1 Study Do 2 Discharge planning checklist 2 3 Hospitalist and resident education 3

Director of Patient Care Services • Nurse Manager • Pe Pediatric c Di Disch charge Discharge Planner • Team Team Social Worker • Pharmacist • Hospitalist • Resident • Performance Excellence •

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

ac account La Lack ck of transpo ount for Percentage of Discharge Delays or >50% of Transportation 10 15 20 25 30 35 0 5 Medications portation and Reasons for patient discharge delays Unspecified Consults of di Nurse coordinator disch Parent charge de d medi Nursing Radiology dica Supplies delays cations 0 10 20 30 40 50 60 70 80 90 100 Cumulative Percentage of Delays (left to right)

Di Disch charge In Interventions Act Plan 1 Study Do

Di Disch charge In Interventions Act Plan 2 Study Do

Di Disch charge In Interventions Act Plan 3 Study Do

Di Disch charges vary over time and d by by season Number of Patient Discharges by Month 200 3 1 2 180 160 140 Patient Discharge Count 120 100 80 60 40 20 0 5 5 5 5 5 6 6 6 6 6 6 6 7 7 7 7 7 7 7 8 5 6 6 6 6 6 7 7 7 7 7 8 8 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - l g p t v c b r n l g p t v c b r n l g p t v c b r n r y n r y n r u c a u c a u c a u o e p a u u o e p a u u o e p e a e e a e e a e J O M J O M J O M A D A M A D A M A D A S N J F J S N J F J S N J F BASELINE INTERVENTION

Intervention improved orders by 10am In s Inspection Unit = 100 Percentage of patients with discharge orders by 10am Jul-15 10 15 20 25 30 35 40 45 0 5 Aug-15 Avg=13.2 LCL=3.3 UCL=23.1 Sep-15 Oct-15 Nov-15 U Chart for Patients with Discharge Orders by 10am Over Time Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Month-Year Dec-16 1 Jan-17 Feb-17 Mar-17 Apr-17 May-17 2 Jun-17 Limits based on subgroups Jul-15 to Nov-16 Jul-17 Aug-17 Sep-17 3 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18

Intervention improved discharge by noon In s Inspection Unit = 100 Percentage patients discharged by noon Jul-15 10 15 20 25 30 35 40 0 5 Aug-15 LCL=3.7 Avg=13.9 UCL=24 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 U-Chart for Patients Discharged by Noon Over Time Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Month-Year Dec-16 1 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 2 Limits based on subgroups Jul-15 to Nov-16 Jul-17 Aug-17 3 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18

In Intervention improved discharge by noon Percentage of Patients Discharged by Noon by Year 1 2 3 40 Monthly Percentage of Discharged 35 Patients Discharged by Noon 30 25 2017 (Intervention) 20 2016 (Baseline) 15 10 5 0 Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

No No statistically significant difference in... • Length of stay index • Child HCAHPs survey • Readmission rates • ED revisit rates

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

Limitations Li ● Limited sample size ● Generalizability Fu Future studies: ● Work on sustainability ● Medication fills ● Extend to other services/units

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

Thank Thank you! ou! Que uestions ons?