Several new initiatives are adding up to better care and discharge planning, and an improved experience for patients on Victoria Hospital’s Level 6 medical unit.
“Our discharge planning has improved 100 per cent,” said Debbie Winge, Nursing Unit Manager for the Level 6 medical unit.
“Our staff and physicians are more aware of the care plan, and, most importantly, patients and their family members have more information about what is happening and why.” (Debbie Winge)
A number of changes were required to improve the discharge process for Level 6 patients. It began with a Rapid Process Improvement Workshop (RPIW) in February 2015. Prior to the RPIW, there were several problem areas identified that were barriers to a timely and efficient discharge process for patients, families, staff members and physicians. There was ineffective or a lack of communication between providers and patients/families. Patients were often confused as to who their care team was and who did what. There was also poor communication and not enough education about how to use tools that would help manage discharge planning, and better predict discharge dates.
The improvement team implemented several changes to improve communication, and also included a training and education plan for staff members and physicians:
- The use of “Patient Status at a Glance” boards was better defined.
- Daily bedside rounds were initiated with nursing and the patient care coordinator (PCC), and included patients (and family when wanted and required).
- Communication with patients and families was also improved by the use of bedside boards in every patient room and a Key to Your Care guide (defines who’s who for patients).
- Standard Work and Work Standards, and an education binder were also developed for staff members.
The RPIW got the ball rolling to improve discharge planning and achieve the planned discharge date. There is now early and frequent communication with patient and family about their plan of care, and a better understanding of who their providers are and their roles.
At about the same time as the RPIW, there was training in the Real Time Demand Capacity for the nursing unit managers at Victoria Hospital. The focus was on predicting the bed needs, and how to ensure the unit and the hospital would have capacity. This included noting planned discharge dates, and utilizing current and historic admission patterns. They had multi-disciplinary rounds that would involve nursing, PCC, pharmacy, occupational therapy, physical therapy, respiratory therapy and others as needed to plan for discharges.
Talking with patients
“We were meeting in a room and talking about the patients. We realized we needed to be talking with the patients.” (Debbie Winge)
They started with bedside rounds with nursing and patient care coordinator for the unit, with one side of the floor (17 patients on each side) every other day. “It was done to keep the focus on what has to be accomplished to plan for discharge,” Winge said.
Last fall, they decided to make the change. As of Dec. 1, 2016, bedside rounds began with inter-disciplinary teams going from patient to patient. They still only do one side of the unit per day, but the improved communication is making a difference.
Bedside rounding is now happening on the three adult inpatient units (Levels 4, 5 and 6). They go at different times, but the goal is the same – review the care plan for the patient, identify areas of concern, and prepare for the patient’’ discharge. This can include use of the D-minus system, where a discharge date is set, and the care planning includes milestones required to meet the discharge date.
“Someone can be medically stable, but there may be other concerns that need to be addressed by the discharge date,” Winge said. “Is there adequate support at home? Would they want to get their medication in blister packs?”
The rounding has improved communications between all staff members and departments involved in patient care, Winge said. “Instead of having to find someone, or search through a chart, we have a time where we can discuss concerns.”
Patients and families were a little reluctant to stay in the room at first. “They thought our discussion meant they had to leave,” Winge said. “Now that we have been doing this for a while, people are more comfortable, and I think they welcome the opportunity to find out more information and ask questions.”
Everyone on the same page
“It is a good thing. It is nice to make sure we are on the same page, and I know what is going on.” (Debra Hills, patient)
There is still a need to improve communication with physicians. With many different physicians responsible for the more than 30 patients on the floor (normal capacity is 34), it would be a challenge to have them all there at the same time for the bedside rounds. However, there have been improvements, with physician alerts about important issues going into the patient chart. This can be questions about medical issues or medications, or other issues that impact the patient and the planning for discharge.
Winge said a major benefit is that patient and family members are now more involved and aware of the care plan and planning for discharge from the hospital. Questions can be answered about support at home after discharge, or discussions about how the patient’s needs may require placement in a personal care home or special care home. “We have seen how it is making a difference in how we support patients and their families both at the hospital, and when they leave the hospital,” said Winge.
A new electronic tool, Sunrise Clinical Manager (SCM), is also helping improve communication and flag tasks. The electronic tool not only provides updates on status for the patients, but nurses and other providers can access notes and other information (lab results, etc.) more easily. SCM has been used in the Emergency Department for several years. It rolled out to the inpatient units in 2015.
Winge said the changes have also resulted in a better understating of the relationship between the inpatient units and the rest of the hospital.
“I think we have a better understanding of how patient flow affects the hospital. When we talked about wait times for surgery or in the ER (Emergency Department), we might not have thought it was relevant to us. With the Real Time Demand Capacity, and the work we are doing, we see how we contribute to improved patient flow for the hospital.” (Debbie Winge)
Photo: Debbie Winge, second from right, Nursing Unit Manager for Level 6 Medicine, and her team includes patient care coordinators and therapies staff, discuss the care plan for patient Debra Hills, left.