Transitions of Care 20,000 Days Campaign Learning Session 3 11-12 March 2013

1. Clinical Lead: Martin Chadwick Team members: Dr Ajay Kumar, Annelize de Wet, Dr Beven Telfer, Brian Gabolinscy, Dr Carl Eagleton, Carolyn Kemp, Catherine Simpson, Chee-Khiang Sng, Clivena Ngatai, Diana Dowdle, Dot McKeen, Erin Currie, Fionna Winter, Fran Birt, Galumaninoa Tasi-Perez, Gregory Winkelmann, Helen Thomas, Ian Kaihe-Wetting, Janene Lawrence, Dr Jeff Garrett, Jo Goodfellow (GAIHN); Karla Rika-Heke, Maika Veikune, Marie Chester, Michele Carsons, Moana Houia-Poka, Penny Wilkings, Ruth Prakash, Sanjoy Nand, Sarah McMullen-Roach, Simon Kerr, Jessica Ryan, Deanna Williams (POAC) 20,000 Days Campaign Project Support: Prem Kumar (Improvement Advisor) Monique Davies (Project Manager) Transitions of Care 20,000 Days Campaign Learning Session 3 11-12 March 2013

2. Refining Our Aim Transitions of Care was a very large collaborative with an even larger brief of improving the inpatient hospital journey and reducing unnecessary delays to discharge. Our original aim: • By 01 July 2013, we will improve the MMH inpatient journey from admission to discharge by utilizing a goal date for discharge and looking to reduce the average length of stay by 0.2 bed days within medical and surgical inpatient services. To assist in reaching this goal we will look to facilitate earlier notification of referrals to appropriate inpatient services and diagnostics, nurse led discharges and weekend discharges. We will also work on our transition of care processes with the patient’s primary healthcare provider. By focussing our improvement work on two work streams: the patient's Goal Discharge date (GDD) and improving the volume of Weekend Discharges we have accomplished a firm direction for testing our improvement ideas. The following two slides show our PDSA progress…..

3. Secondary Drivers Tertiary Drivers Primary Drivers Specific Change Ideas (PDSA tests) Change Concepts Transition of Care Driver Diagram-v5 Date: 4 July 2012 Admission Process Advance Planning • GDD for each patient X Discharge decision making • Rapid ward rounds MDT availability Timely decision making Ward round Care pathway STAAR Timeliness of documentation Discharge checklist in ward X Discharge documentation Ticket for Discharge Quality of documentation Simplify Discharge planning Standardisation Shared care plan PT self mgmt Pt involvement Pt Education Prevention (Rapid Response) Post Disch phone call Family • Patient awareness on EDD communication to family Discharge communication Advice family on EDD To improve the admission to discharge process of Middlemore Hospital inpatients by 01 July 2013 Communication Communication to Primary/Res. care Verbal handover Coordination Effective handover Improve transport delay St John ordering process Stoking of equipment Treatment Transfers CMDHB to own and have equipment POAC Measures: 1. LOS 2. Readmission 3. Pt Experience Correct Prediction of equipment Discharge /Transition lounge Std wknd plan-Dx info in one place with reasons Access to Diagnostics Use A2D planner for Dx X-Ray, U/S, CT Measures: 1. ALOS 2. Readmission 3. Pt Experience Self Dx Bloods Patient held care plan (Passport) Share team contact with pt for Dx follow up Measures: 1. LOS 2. Readmission 3. # of Pt discharged Discharge clinical decision making Availability of Consultant ? Pt booked in for GP post Dx MDT Access Accessibility Weekend rounding Access to Diagnostics Weekend discharge community resources Pilot nurse led discharge Pt to have Dx date & time Availability Increase the use of POAC Home+ community services 7 day staffing Combined EDS for all service (MDT led Dx) Formal process for Pt review-Task Mgr

4. Transition of Care PDSA Tree Date: 27/11/2012 Reviewed 27/02/2013 Active PDSA 7 Nurse setting the GDD Pt awareness on GDD Staff to set a GDD based on the top 10 DRGs-Michele 5/12 GDD match with actual Dx date Reason of GDD not met-Ruth& Michele 12/12 Who, How, When? Staff awareness on GDD GDD in MDT meeting Establish GDD & Daily Review Doc to use care plan to review GDD-Ruth/Michele 5/12 Pt awareness on GDD-Surgical To have a standardised process to provide each patient with a GDD How and what is the best way to establish a GDD? # of clinical directors believe in establishing GDD GDD by Doc post acute ward round – Brian 17/12 Check consultant aware of GDD in mind Process Map Janene/Michele 23/1 GDD in ward 33 Janene & Michele 23/1 Is the GDD documented on care plan? GDD mentioned in notes GDD given to surgical pt and any plans documented CAT tool to indentify why Pt waiting CAT tool usefulness Reasons of Pt waiting on Bed Post ward round delay in services for Pt > 7 days Goal Discharge Date PDSA Summary Tree Goal Discharge Date Pt less than 48 hour Cultural Support to inform – Maika/Ian 23/12 Patient & Family Nurse to inform Pt- Ruth Aim: To improve the number of inpatients having GDD from 0% to 100% also To increase the number of inpatients achieving the GDD for from 0% to 100% by July 2013. Sharing GDD DOC to use care plan for updated GDD info Doc reviewing /confirming GDD-Ajay 5/12 Drs To have a standardised process to share GDD Best way to communicate the GDD to patient and interested parties? Update GDD on white board Staff Update GDD on WiMS Other Services E-referral – Erin 5/12 Ascertain ref process in ward 6 PDSA box Timely task referral Repeat PDSA Active PDSA Adopt Adapt Abandon What's Happening Prediction: GDD will improve the patient experience and efficiency. Also this will reduce the LoS What ref system are available in service dir. Achieving the GDD Identifying Pt need @ admission in EC 4 pts (Ajay Kumar/ Fionna W) 13/1 Identifying Pt need @ admission in EC (Ajay Kumar/ Fionna W) Repeat with interventions To have the processes in place to achieve the GDD How can we achieve the GDD as a team Early Dx if Pr referred to NASC earlier Delay in x-fer to rehab Referral system assessment & documentation from acute to AT&R HHC to receive Dx list twice daily Known patient dx communication to HHC Discharge to HHC Owner: Prem Kumar

5. Transition of Care PDSA Tree Date: 27/02/2013 Active PDSA 9 Call On Call Dr to clear the delay in Dx for non medical reasons –Fionna 13/12 How many didn’t meet criteria & why? Fionna 5/12 Who, How, When? Identify the criteria for Dx Nurse Facilitated Dx Process Mapping Identify the Dx patient on Friday – Fionna 5/12 Using task manager for NFD referral –Fionna 13/02 Measures: No of NFDx Using task manager for medical review-Brian 13/2 Criteria Led Dx How many weekend reviews Weekend Discharge Causes of less ref-Clivena 20/2 Weekend Discharge PDSA Summary Tree Increase referral to POAC Knowledge & understanding Ward 2 identification of pt for POAC Brian/Fiona Aim: By 01 July 2013, we will increase by 20% the number of Middlemore Hospital medical and surgical inpatients discharged on Saturdays and Sundays. Measures: No of referrals All patients have weekend plan To identify pt with no clear plan and require a non medical input –Fionna 5/12 Test Ward 2 template for weekend plan-Sarah 1.Clarity on why they waiting on weekend 2.Why not clear All Pt have weekend plan Test the template in medical ward-Fionna 13/2 Measures: Weekend plan are clear Measures: No of weekend Dx Readmission rate 3 Day Dx for weekend (OT) Identify delay in Dx (OT) -Sarah PDSA box No Time Barriers to Dx to RH – David Lange RH Active PDSA Adopt Adapt Abandon What's Happening Delay due to IV Identify the reasons for delay with Radiology -Beven 20/02 Chart review to ascertain reason for delay for PICC Transfer to AT&R Pt Transfer Rest home baseline Penny/Prem Fit for Dx but delay due to rest home 30/01 Reasons for delay in tfr to rest home on 10 pt-Fionna 27/02

6. Goal Discharge DateChange Packages Examples

7. Goal Discharge DateChange Packages Examples…cont

8. Weekend Discharge Change Package Examples

9. Weekend Discharge Change Package Examples…cont

10. Most Successful PDSA Cycles? One of our most successful test of change was around the communication of GDD to staff and other services. Change Idea: to communicate the GDD to the multidisciplinary team by pitting the GDD on the WiMS sheet Learning/Outcomes: updating of GDD in WiMS assisted the information about the patient’s GDD to be readily available to all staff involved in that patient’s care at any time

11. Measures Summary

12. Highlights Direction and Purpose The group now have clarity of direction by the focus on two work stream areas: Goal Discharge Date and Weekend Discharge PDSA tests are completed, recorded and discussed at weekly meetings The IHI PDSA Methodology is now well embedded and learning is gained from each PDSA cycle, in some instances we learn more from our ‘failures’ than our successes Working with the David Lange Rest home on our current PDSA “No Time Barriers To Discharge to a Rest Home” has highlighted the willingness and generosity of primary care and community organizations to be part of our improvement journey Strengthening of relationships between services and professions has been a highlight of working within this group

13. Achievements to date • The group have established and bedded in the process for setting a goal discharge date in ward 6 and have worked to look at rolling out to wards 33N and 2. Data on the accuracy and consistency of recording of the GDD is collected and presented weekly • The effect of a ‘published’ GDD for patients on these wards has a marked beneficial impact on other staff in the planning and provision of allied support services • Measurements established to look at the volume of weekend discharges, referrals for discharge to the Nurse Facilitated Discharge team on weekends and POAC assisted discharges