90 Seconds of Focused Team Conversation - AONE - The … · 90 Seconds of Focused Team Conversation...
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90 Seconds of Focused Team Conversation to Reduce LOS and Address the Triple AIM! Session 406 Mary Reyes-Gonzales, MSN, RN-BC, NMF William Stanford, MD, PhD Nina Tabachnikov, BSN, WCC Mark Redulla, MSN, NE-BC Sissie McElvaine, MSN, RN-BC Cedars-Sinai Medical Center Los Angeles, CA
Transcript of 90 Seconds of Focused Team Conversation - AONE - The … · 90 Seconds of Focused Team Conversation...
90 Seconds of Focused
Team Conversation to Reduce LOS and Address
the Triple AIM!
Session 406
Mary Reyes-Gonzales, MSN, RN-BC, NMF
William Stanford, MD, PhDNina Tabachnikov, BSN, WCC
Mark Redulla, MSN, NE-BC
Sissie McElvaine, MSN, RN-BC
Cedars-Sinai Medical Center
Los Angeles, CA
90 Seconds of Focused Team Conversation to reduce the LOS and Address and Triple AIM!
Cedars-Sinai is one of the largest
nonprofit academic medical centers in the
U.S. with 886 licensed beds, 2,100
physicians, 3,100 nurses and thousands
of other healthcare professionals and
staff. Clinical programs range from
primary care for preventing, diagnosing
and treating common conditions to
specialized treatments for rare, complex
and advanced illnesses
Objectives
• Discuss how an innovated and enhanced type of progression of
care rounds can reduce length of stay.
• Describe the roles each member of the interdisciplinary team can
have on providing efficient and coordinated care.
• Summarize what is needed to replicate the program utilizing the
necessary team members.
Progression of Care Rounds – Standardization goals
Physician Advocate Role
POCR Team Roles and Responsibilities
Nursing Tools
Results
Training Topics
Progression of Care Rounds OverviewProblem: Care delivery at hospitals can be disjointed, resulting in
suboptimal care for our patients.
Progression of Care Rounds Goal:
To improve care delivery to patients
through multidisciplinary care
coordination.
Key discussion points:
✓Why is the patient hospitalized?
✓ Plan for the day
✓ Medication issues
✓ Patient questions/concerns
✓ Discharge plan
Nursing Pharmacy
Case Management/
Social Work
Physician Advocates
Effective Care Coordination
Key POCR Definitions
• The predicted length total of stay for an individual patient based on the principle diagnosis or working DRG
Estimated Length of Stay (ELOS)
• The date based on the ELOS that the patient should be discharged; Also referred to for conversations with attendings as “Earliest Anticipated Discharge’ (EAD)
Expected Discharge Date (EDD) - or -
Earliest Anticipated Discharge (EAD)
• The Clinical Document Integrity specialist who rounds on the patients and reviews the documentation in the patient’s medical record to validate that it meets Medicare criteria
Clinical Documentation Specialist (CDS)
• The national mean LOS for each DRG as determined and published by CMS
Geometric Length of Stay (GMLOS)
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POCR Operational Process
Who
• RNs, CMs, SWs, Pharmacists, Physician Advocates, and ancillaries (e.g. dietary, therapy, chaplain) will meet for POCR to determine the plan for the stay. RNs will update patient care board and complete follow-up on all unresolved disposition of activities of the plan for the day
What• The goal of POCR will help care team appropriately progress patients to the next
level of care
When• Daily - At the same time lasting no more than 45 minutes
Where• In each unit in the same place and location
How
• Nurses will be responsible for following the POCR template and effectively update care team on patient’s progress and care plan; charge nurses will keep sequencing nurses during rounds in order to minimize disruption and delay
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Leading Effective Care Rounds: Who is included?
• Facilitator• Manager, ANM, CM, Charge RN
• Consultations
• Case Manager
• Social Worker
• Pharmacist
• Physical Therapy
• Chaplain
• Dietician
• Physician Advocate
Staff Nurse Follow-up Process with Charge NurseTIME of Day Process Tool Communication
830am -11 am POC Rounds Presentation template Verbal during POCR
11am – 3 pm Resolution of Issues assigned by CN Verbal – ongoing thru shift
issues or teamwork on updates between
suggestions nurse/CN/CM/SW
from POCR
11am – 5 pm Escalation for Text, call or email Phone/text/email flag to PA/Medical
those issues Director/Medical staff leadership
needing medical
staff leadership
3-5 pm Huddle w/CN/ Follow-up template Verbal check-off of issues resolved
CM/SW/RN census list notes Written template to evening
CN for f/u
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RN CM/SW
Charge RN
AOD/
Attending MD
ANM/
Nurse Manager/
Attending MD
Weekends/
Off hours
Regular business
hours
PA
Attending MD-Surgeon
or Internist
Vice Chair
Medicine/Surgery
PA/Case
Management
Medical Director
For Information
For escalation
Escalation of Follow-up Issues Without Resolution
As needed
Training Topics
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Progression of Care Rounds
Physician Advocate Role
POCR Team Roles and Responsibilities
Nursing Tools
Results
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Roles and Responsibilities -Physician Advocates
Anticipates patient and provider needs
Facilitates interdisciplinary communication
Escalates issues when appropriate
Serves as clinical resource for
discharge planning
Supports staff education
POCRDr. Bill Stanford5SE and 5SW
Dr. Harry Sax7NE and 7NW
Dr. Chase Coffey5NE and 5NW
Dr. Henry Horton7 SE
Dr. Natti Thepyasuwan4 SE
Dr. Shahida Farooqi, MD4NW
Dr. Aditi Nag4NW
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Physician Advocate:
Roles and Responsibilities
Case Managers
Nursing Staff
Social Workers
Attending Physicians
Pharmacists
Physician Advocate
Roles and Responsibilities for Physician Advocates
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Review and discuss all aspects of the hospitalized patient’s experience, with special focus on patient safety, efficiency, and preparation for care transitions / Discusses EAD
Expedite care delivery by anticipating the needs of the patient and attending MD
Facilitate interdisciplinary communication and care coordination
Serve as a clinical resource to staff for care coordination and care transitions
Educate staff on clinical issues relevant to patient care
Identify and improve gaps in documentation through collaboration with the Clinical Documentation Management Program
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Physician Advocate Selection Criteria
Candidate FY15 LOSi
(35%)
Candidate FY15 Mortality Index (15%)
Candidate Hospital Admitting
Experience (15%)
MD-RN Collaborative
Subjective Evaluation (35%)
• >1 year experience admitting patients
• Candidate LOSi < than facility average• Minimum 100 patient cases in FY 15
• Minimum aggregate subjective average interview score 2.5
• Minimum 2.0 average score across all areas
Physician Advocate Minimum Qualifications:
Training Topics
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Progression of Care Rounds
Physician Advocate Role
POCR Team Roles and Responsibilities
Nursing Tools
Results
Roles and Responsibilities for Nursing
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Bedside Nurse
• Utilizes a standardized script template for reporting and tracking
clinical info
• Performs admission assessment and identifies frailty patients
• Determines plan of care for POCR and discusses with Attending and
POCR members
• Reports patient progress to POCR and follows up based on POCR
Team recommendations
• Communicates POCR recommendations to Attending and verbalizes
at POCR
• Educates patients to ensure knowledge of discharge and purpose of
EAD
• Enters EAD on white board after POCR discussion
Nursing Summary Template
High Level Patient Summary
Today’s Treatment Plan
Issues or Concerns
Frailty
Unit Specific Issues
Discharge Plan
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Roles and Responsibilities for Nursing
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Charge Nurse
• Leads POC Rounds as assigned or in absence of CM/SW/PA and
provides input about patient situations
• Discusses discharge plan with patient and family to identify options
and barriers for EAD; inputs EAD on patient whiteboard if not done
by bedside nurse
• Monitors and resolves delays on tests, orders, and consults
• Keeps POC rounds moving smoothly to make sure bedside nurses
are ready to participate
• Utilizes the Follow-Up Tool to capture outstanding action items and
their resolution
Roles and Responsibilities for Nursing
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Nursing Manager/ANM• Supports POCR efforts on unit and participates periodically to
ensure POCR standards
• Provides feedback about the rounds as needed
• Assist with issues that need to be escalated that are delaying the
POC and discharge
POCR Facilitator:
Listens to nurse presentation:
• Notes age, gender, diagnosis & symptoms or problem list, and
day # or POD #
• Reviews tests/procedures scheduled
• Reviews am labs – electrolyte replacement, blood transfusion,
etc.
• Ensures RN presents all required elements of POCR
presentation list
• Engages the POCR Interdisciplinary members
Roles and Responsibilities for Other POCR Members
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Case Manager• Identifies correct status and admission order during POC Rounds• Validates expected discharge date with Attending and discusses with
team at POC Rounds• Collaborates with POCR Team on discharge plan, Expected LOS, and the
means to achieve it• Inputs expected discharge date on CS-Link Banner• Identifies barriers to the Progression of Care and defines what needs to be
done for safe discharge
CDS• Communicates GMLOS of working DRG to CM when available• Notifies CM and/or PA of outstanding queries prior to expected discharge
date • Collaborates with CM and/or PA in obtaining documentation to justify
Severity of Illness and continued stay• Identifies primary diagnosis and DRG LOS• Identifies cc/mcc for documentation needs
Roles and Responsibilities for Other POCR Members
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Social Worker
•Completes the initial patient assessment and discusses frailty during
POC Rounds
•Identifies discharge plan post assessment and communicates discharge
placement/disposition at POC Rounds
•Confirms discharge plan with patient and family; communicates with
attending as appropriate
•Directs implementation of activities needed to facilitate a safe discharge
and ensure post discharge needs are met
Pharmacist
•Completes medication assessment for frailty patients and/or evaluates
medication regimen for recommendations/prevention of ADR
•Makes recommendations for continuation of therapy to progress towards
discharge and post-discharge needs
•Reviews labs, procedures, tests, and NPO status to monitor for
adjustment
•Active antibiotic stewardship
•Answers drug questions from POCR team
Roles and Responsibilities for Night Shift Nursing
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Night Charge Nurse
• Identify patient needs and efficiently address as soon as possible.
• Identify and address patient needs that may delay or hinder
discharge for the next day.
• Communicate with day charge nurse at handoff to facilitate more
efficient patient discharge.
Opportunities for the Night Shift
• Assist with early discharges: lab work or procedures ordered and
performed on time.
• Discussion opportunities with patient and family members regarding
discharge time….11am and transportation needs
• As physicians round at night: Suggest writing discharge.
prescriptions and DME as needed.
• Discharge paperwork/Education.
Training Topics
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Progression of Care Rounds
Physician Advocate Role
POCR Team Roles and Responsibilities
Nursing Tools
Results
Follow Up Tool for Charge Nurse and EvaluatorROOM Follow Up Needed Done Not Done: Why? Escalation Issues
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3
5
7
9
11
13
15
17
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21
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25
27
29
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Unit: Charge/Evaluator:
Date:
Sa,
Operational Process: Hand-Offs Worksheet
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Operational Process: Follow up worksheet
ALL FOLLOW UP MUST BE COMPLETED BY 15:00. SUBMIT THIS FOLLOW UP SHEET TO THE CNIV/CN.
Acknowledgement follow up is complete: __________________________________ Date: _______________ Please print and sign
Room # Room# Room# Room #
o Central Line documentation
o Central Line documentation
o Central Line documentation
o Central Line documentation
o Consult request o Consult request o Consult request o Consult request
o D/C Foley o D/C Foley o D/C Foley o D/C Foley
o D/C Lines o D/C Lines o D/C Lines o D/C Lines
o D/C PCU Status o D/C PCU Status o D/C PCU Status o D/C PCU Status
o D/C Tele o D/C Tele o D/C Tele o D/C Tele
o Discharge plan o Discharge plan o Discharge plan o Discharge plan
o Lab follow up o Lab follow up o Lab follow up o Lab follow up
o Medication change_____________
o Medication change_____________
o Medication change_____________
o Medication change_____________
o Procedure results______________
o Procedure results______________
o Procedure results______________
o Procedure results______________
o PT/OT EVAL o PT/OT EVAL o PT/OT EVAL o PT/OT EVAL
o Transfer NMB o Transfer NMB o Transfer NMB o Transfer NMB
o VTE documentation o VTE documentation o VTE documentation o VTE documentation
o Other _______________
o Other _______________
o Other _______________
o Other _______________
o Other _______________
o Other _______________
o Other _______________
o Other _______________
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Training Topics
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Progression of Care Rounds
Physician Advocate Role
POCR Team Roles and Responsibilities
Nursing Role and Responsibilities
Results
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What’s Different?
Nursing Pharmacy
Case Management/
Social WorkPhysician Advocates
Effective Progression of
Care to Discharge
4.78
5.81
4.38
5.86
0
1
2
3
4
5
6
7
PA Units Non PA Units
Results: Average Length of Stay (ALOS)July – Jan FY 14 vs July – Jan FY 15
PA Units Non PA Units
CMI 1.65n=6,922
CMI 2.20n=12,166
CMI 1.66n=7,680
CMI 2.33n=12,298
ALOS (July –Jan FY14)
ALOS (July –Jan FY15)
Results: Length of Stay Index (LOSi)July – Jan FY 14 vs July – Jan FY 15
0.80
0.85
0.90
0.95
1.00
1.05
PA Medical Units Non PA Medical Units
CMI 1.65n=6,922
CMI 1.66n=7,680
CMI 2.20n=12,166
CMI 2.33n=12,298
PA Units Non PA Units
1.00
0.89
1.03
0.98
LOSi(July –Jan FY14)
LOSi(July –Jan FY15)
Results: Readmission RateJuly – Jan FY 14 vs July – Jan FY 15
12.2%
13.1%
12.2%
13.8%
11.0%
11.5%
12.0%
12.5%
13.0%
13.5%
14.0%
PA Units Non PA Units
PA Units Non PA Units
CMI 1.65n=6,922
CMI 1.66n=7,680
CMI 2.20n=12,166
CMI 2.33n=12,298
Readmission (July –Jan FY14)
Readmission (July –Jan FY15)
Progression of Care Rounds
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Benefits of Daily POCR
Provides communication venue for multidisciplinary team
Increase team collaboration
Clarify point of care
Identifies and addresses barriers to discharge
Supports improved documentation
Provides nursing and physician education
Progression of Care Rounds
Teamwork divides the task and multiplies the success.
Therefore, in order to be successful, everyone needs to know their role in the process.
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Next Steps…
• House wide Implementation
• Frailty Focus
• Med Rec Focus
• Preventing Readmission Task Force
Questions
Acknowledgements
• High Value Care Committee/Administration
• Linda Burnes Bolton, DrPH, RN, FAAN, CNE of Cedars-Sinai Health System
• Peachy Hain, MSN, RN-BC, Director of Med Surg & Rehab
• Todd Griner, MSN, NEA-BC Director of Critical Care Services
• Carol Beehler, MSN, Interim Manager of Case Management
• Joyce Brempong, BSN, RN-BC, CNIV
• Performance Improvement
• Pharmacy Department
• Dietary Department
• Spiritual Care Department
• Physical Therapy Department
• Nursing Team
Contact Information
Mary Reyes-Gonzales, MSN, RN-BC, NMF
Cedars-Sinai Medical Center
William Stanford, MD, PhD
Stanford Hospitalist Medical Group
Cedars-Sinai Medical Center
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