Patricia Maurer RNC MBA MSN, Megan Strohecker …...DISCHARGE TIMELINESS FOR MOTHER BABY : A SIX...
Transcript of Patricia Maurer RNC MBA MSN, Megan Strohecker …...DISCHARGE TIMELINESS FOR MOTHER BABY : A SIX...
DISCHARGE TIMELINESS FOR MOTHER BABY :
A SIX SIGMA PROJECT TO IMPROVE THROUGHPUT Patricia Maurer RNC MBA MSN, Megan Strohecker RNC BSN, Barb Emberg, Pinnacle Health System
DEFINE IMPLEMENTATION IMPROVE
Baseline Maternity Throughput Metrics from March 2008
MATERNITY THROUGHPUT GOALS
MEASURE//ANALYZE
Opportunity/Problem Statement Problem: Capacity on Postpartum Unit delayed care of
patients coming into L&D for treatment and delivery. Delayed
discharges compromised patient safety, patient and
physician satisfaction, and facility revenues
Scope: An interdisciplinary team addressed processes that
impacted timeliness of Mother/Baby discharges from the
Postpartum Unit to expedite the discharge process and
transfer of patients from L&D.
Areas Stabilized Through Collaboration of Team
Discharge order time for Pediatricians and Obstetricians
Services provided day before discharge
Circumcisions
Hearing tests
Car Seat Safety instructions
Photography services
Social Services intervention
Paperwork completed by patient evening before
discharge
The analysis of the baseline throughput metrics:
69.1% of discharged patients left after 1200 through afternoon and evening hours
of each day
55% of the infant deliveries occurred during the time frame
indicates a low throughput daily
Lack of capacity during certain times of the day.
: Stabilization of services before the day of discharge did not significantly
improve throughput
Processes on day of discharge were not addressed initially
•Improve the time patient leaves the hospital by 1200 from
31.5% to 50%
•Decrease the time period between when the Mother/Baby
couplet is discharged and when the couplet departs from the
hospital : 75% of Mother/Baby Couplets will depart within
90 minutes of last discharge.
•Improve the skill level of charge nurse to manage
throughput
To meet these goals the DMAIC (Define, Measure Analyze,
Implement/Improve, Control) methodology of Lean Six Sigma was
applied.
Avg. Daily ED Volume vs. Avg. Providers
Designate Charge Nurse Role
The Charge Nurse is a pivotal role in the promotion of an efficient
Postpartum Throughput process. The Charge Nurse role was being
rotated among nurses with different understanding and skill levels
and it was preventing the standardization of Postpartum
Throughput. Designating a core group of Charge Nurses with
superior skills based on the Charge Nurse Characteristics
Evaluation Tool, were assigned to the role on downshift. They were
educated about throughput, instructed to relate discharged patients
to each staff nurse. Throughput improved to 39% with mother/baby
couplets leaving the unit within 90 minutes of the last discharge
written, either mother or baby in Rapid Cycle 1. Delayed discharges
were due to infant diagnostic testing, patient readiness,
transportation to home, Lactation Consult needed but not done, and
circumcision not done
.Maternity Discharge Work flow
Rapid cycle II maintained the utilization of the charge nurse core
group. An alert was created and implemented within the electronic
documentation system to alert the nurse when the mother/baby
couplet were discharged by the physician. Throughput improved to
47% of mother/baby couplets leaving the unit within 90 minutes after
the discharge was written for either mother or baby in Rapid cycle
II.. Delayed discharges due to infant diagnostics, patient readiness,
and circumcision done on day of discharge.
Maternity Expected Discharge List
Maternity Expected Discharge List was developed. Patients for
potential discharge the next day were listed. Staff nurses provided
the patients information about discharge time before 1200, to secure
transportation home, and completion of individualized education
based on The Maternal Education Assessment, completed by each
postpartum patient. 52% of mother/baby couplets departed the unit
by 1200 and 49% departed within 90 minutes of last mother or baby
discharge in rapid cycle III. Delays were due to mother with NICU
baby, transportation home, circumcision and infant diagnostics
Lactation Consultation
Electronic consultation was developed within EMR. Consultation
was initiated by nursing assessment of potential or active problems
with breastfeeding. Lactation Consultants used a portable laptop to
prioritize work list, document assessment, education and plan of
care, with nursing and pediatrician accessibility for review. Initial
consultations on the day of discharge declined, communication
improved as well as quality of interdisciplinary care
Photo Therapy Equipment Consignment
Agreement with Equipment company provided storage of bili-
blankets for home photo therapy eliminating waiting for delivery
Use of Teletracking with Transport Aide
Next day discharges were entered in electronic system. Activated
alert to transport of readiness to depart. Patient escorted to
transportation within 10 to 20 minutes.
.PROCESSES ON DAY OF DISCHARGE
Control reports are critical in the DMAIC cycle to gain consistency in
performance and sustain the gains.
18.5%
24.8%
31.5%
25.1%
0.4%
30.5%
65.8%
3.3%
20.4%
19.0%
31.9%
28.7%
14.4%
38.0%
31.3%
16.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total Births Time Pt Left NVD C/S
Births by Time of Day and Time Patient Left M9
1800-0000
1200-1800
0700-1200
0000-0700
1. Charge Nurse:
Effectiveness to manage throughput impacted
Timeliness of discharges
2. Staff nurses:
Not aware when discharge written by either Pediatrician
or Obstetrician
3. Patient Readiness for Discharge
Patient delays to departing on day of discharge
included transportation arrival time, knowledge of discharge
Time of 1200 to depart, completion of education to prepare for care of self and
infant
4. Services received on day of discharge
Discharge instruction completion, Diagnostic testing on
some infants, Equipment delivery for infant home photo
therapy for treatment of hyperbilirubinemia, Lactation
needed for pump rentals or consultation
5. Physician discharge times after 1200: 12.9% for Pediatricians, 9.5%
for Obstetricians
20.40%
30.94%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Baseline Aug-Oct
% Discharge by 1200
% Discharge by 1200
65.6%
62.3%
14.9%
13.6% 10.0%
11.2%9.5%
12.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0500-1000 1000-1100 1100-1200 After 1200
Physician Discharge Time - Aug 23 to Oct 1
OB Discharge
Ped Discharge
CONTROL
Rapid Cycle Progression depicts optimal outcomes with 47%
of mother/baby couplets leaving the unit within Rapid Cycle
Three.
Discharge departures within 90 minutes of last discharge in
last quarter of 2009 and first two quarters of 2010 declined.
Individual couplet services and personal choice impacted the
data. Open beds at 1200 was more important for throughput.
Couplet discharge time by 1200 percentages improved
through the second quarter of 2010 to 83%.
Teletracking electronic data collection assists to monitor
couplet discharge times. Discharge time by 1200 has
been normalized by stakeholders. This set of data depicts
the time the couplets were in transport to home with the
transport aide ending the transaction.