Releasing Time to Care Vancouver Coastal Health

BCPSQC Quality Forum March 1, 2013

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VCH Releasing Time to Care

Quality Forum Presentation 2013

• Felicia Laing Quality & Patient Safety Project Manager

• Lorelei Grosser LEAN Coordinator

• Natalie Shein RN 2South

• Sara Fatehifar LPN 3South

• Alicia Escobido LPN 3South

• Audra Leopold LPN 3North

• Jacquie Miller RN SGH

• Cindy Sellers Manager Acute Services Sea to Sky

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• Demonstration Project

• Squamish General – rural

• Richmond Hospital – 3 medical units

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Leadership Support

• RT2C Steering Committee

• Visit Pyramid

• Site Tours

• Facilitation by Squamish – LEAN

Coordinator

Richmond: Quality Project Manager & LEAN Coordinator

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The VCH RT2C Team

• Ward Leads – bedside nurse dedicates one shift per week

• Engagement of all staff

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Knowing How We’re Doing Determine unit-based measures to improve

Improve patient safety and reliability of

care

• Infection rates (MRSA, UTI, C.diff…)

• Hand Hygiene compliance rate

• In-hospital falls

• Timing of meal delivery

• Patient transfers

Improve patient experience

• Acute care patient experience

• Patient Satisfaction Survey

Improve staff well-being

• Survey/Dot-voting

• QI knowledge

• Staff absence

• Overtime

Improve efficiency of care

• Volume of patient admissions

• Direct care time

• LOS

• Readmission rates

• Materials and Stocking

• Bed moves

Program costs: • Training and education

• Staff appointed to the RT2C program • Products purchased (visual boards,

equipment, support package) • Consultancy support

Courtesy of S. Raschka

Goal

• Increase nursing time for direct patient care to 60% or more within 12 months of starting the foundational modules

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Knowing How We’re Doing

0%

20%

40%

60%

80%

100%

SGH 3North 3South 2South

26% 27% 34% 31%

Direct Care Time Baseline

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Knowing How We’re Doing

Direct care, 26%

Motion, 11%

Admin, 7% Handovers, 7%

Medicines management,

9%

Discussion, 18%

Personal hygiene, 2%

Patient flow, 1%

Other, 16%

SGH Activity Follow March 29, 2012 Day Shift

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“This is the first time in my 30 years of nursing where I've seen frontline staff get involved with any quality improvement. I really believe that this will work and will be sustainable.”

- Educator

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“Releasing Time to Care gives us more time at the bedside and we're achieving a new level of team work.”

– Staff Nurse

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2 South Medical Richmond Hospital

2 South – Bed Moves

• 140 bed moves in 4 month period

• Average 35 bed moves/month

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Isolation Acuity

Percentage 38% 62%

Total 53 87

0%

10%

20%

30%

40%

50%

60%

70%%

Rea

son

fo

r M

ove

s

Bed Moves by Category 2S August 2012 - November 2012

Take bed with P1 out

-Take IV pole -Move side table, overbed table, all furniture (ie. bedside chair), equipment (ie. commode), personal belongings

Isolation Bed Move

P1 = Regular Patient P2 = Patients who needs isolation Room 1 = Regular patient’s single room Room 2 = Multiple bed room of P2

P 1 P 2

P1 waiting in hallway

Cleaning Room 1

Move P1 into Room 2

-Take IV pole -Move side table, overbed table, all furniture (ie. bedside chair), equipment (ie. commode), personal belongings

Move P2 into Room 1

-Take IV pole -Move side table, overbed table, all furniture (ie. bedside chair), equipment (ie. commode), personal belongings

Housekeeping Cleaning Room 2

Paper work

5-10 mins

15-30 mins

5-10 mins

5-10 mins

20-30 mins

5-10 mins

15 mins

2 South – Bed Moves

• Impact on staff

– Time away from patients

– 15 minutes to move 2 patients

– 3 nurses involved

– 26.2 nursing hours per month

– 315.0 nursing hours in one year

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2 South – Bed Moves

• Impact on patient and family

– Anxiety

– Change in location

– Delayed med administration

– Increased medication errors

– Delayed care from Allied Team

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Outcomes and Next Steps

• Data made Leadership aware of issue

• ER prioritizes telemetry patients to 2S

• Team Leaders change to 12 hr shifts

• Restart Safety Cross to evaluate

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3 South Medical Richmond Hospital

Ranged from 5mins to 110mins Average time 13mins to get patient ready for transfer Courtesy of LEAN Green Belt Program – A. Dosangh, S. Cole

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3 South - Patient Transfers

• Nurse searches and preps stretcher

• Multiple call bells going off and not answered

• Patient moved from room to outside nursing station – no call bell

Ranged from 1min to 38mins Average wait time in hallway 12mins Courtesy of LEAN Green Belt Program – A. Dosangh, S. Cole

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3 South – Patient Transfers

Observations:

• Patient returns and is parked in hallway outside room

• Patient nauseated and vomiting

• – given tray and left at nursing station

• Patient continues to call out in discomfort

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Next Steps

Trial with Porters

• Unit is called ahead of time and Porter helps ready patient

• All nurses are expected to assist with any transfer

• Measure improvement

• Developed an SOP

• Post Observations

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To accomplish great things we must first dream, then visualize, then plan, believe and act.

~ Alfred A. Montapert

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3 North Medical Richmond Hospital

3 North - Falls

• Patient population

– Older adults at high risk for falls

– Decreased mobility

– Dementia

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3 North - Falls

• Average 5.5 falls per month

• Staff unaware # of falls

• Underreporting – falls definition clarified

• Under-using bed alarms

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Attemptingto sit

Getting in /out of bed /

crib /stretcher

Involvingequipment

Turning/moving inbed / crib /stretcher /

chair

Using toilet/ commode

Walkingwithout

assistance,assistivedevice or

equipment

Walkingwith

assistance,assistivedevice or

equipment

UnknownAttempting

to stand

Bending/leaning/reac

hing

Fainted/collapsed

Other

Transferringto or from

bed/chair/stroller

% 6% 16% 3% 3% 19% 9% 3% 3% 19% 6% 0% 9% 3%

Total # 2 5 1 1 6 3 1 1 6 2 0 3 1

0%

5%

10%

15%

20%

25%

30%

35%

40%

% O

ccu

rre

nce

Reasons for Falls - 3N July 2012 to January 2013

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July Aug Sept Oct Nov Dec Jan-13

# Falls (Safety Cross) 8 1 5 5 12 9 4

0

2

4

6

8

10

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Number of patient falls

# Falls RH 3North

Goal: To reduce falls by 50% by June 2013 to 3 falls per month.

Median = 5.5

-Risk assessment on admission

-Families pamphlet on fall prevention -Motion-sensored lights in all rooms -LOM on white boards

-Yconnectors with each bed alarm -Safety checks qshift

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3North - Well Organized Ward

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Relocating Patient Toileting Supplies

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X

X

WOW Relocating Patient Toileting Supplies

Description Before After Savings

Walking Time 3 min 39 sec 1 min 20 sec 178 hrs per patient per year

# of Steps 211 126 248,200 steps per patient per year

Km Walked 0.16 0.10 175.2 km per patient per year

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Next Steps

• Reorganize clean core

• Install shelving units to provide access from each end of hallway

• Partner with Distribution to maintain stock at each location

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Squamish General Hospital

Patient Status at a Glance (PSAG)

What is PSAG?

• A module that encourages frontline staff to develop a customized patient information board.

• Visual management is used to communicate the status of a patient to support staff.

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Patient Status at a Glance (PSAG)

What is the purpose?

• Create a visual plan for the individual patient’s journey during their hospital stay.

• Reduce staff interruptions related to patient status inquiries.

• Improve patient safety.

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Module Initiation

Activity Follow Results • Day Shift – 110

Interruptions to patient care in twelve hours – 36% of interruptions

were directly related to patient status

• Night Shift – 48 Interruptions to patient care in twelve hours – 41% of the interruptions

were directly related to patient status

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PSAG Implementation

• Staff Interviews

• Dot vote regarding content of PSAG

• Review of PSAG board examples from other facilities

• Template trial

• Daily audits to evaluate the new template

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The New PSAG Board

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Impact and Sustainment

• Weekly audits

• Staff feedback

• Education of staff regarding use and goals of the PSAG board.

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The Future of PSAG

• Improved staff satisfaction and less interruptions.

• Continue with weekly audits of the PSAG Board.

• Repeat the activity follow to quantify the reduction of interruptions.

• Celebrate our success!

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Manager’s Perspective

Getting Started • Ensure support and

agreement of your management team

• Funding

• ALL departments involved in delivery of care will need to participate

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Challenges

• There will be a few skeptics. Focus on harnessing their expertise.

• As the manager you need ‘TO LET

GO’.

• It may expose any unresolved issues, disputes or frustrations within your team.

• Workload increases initially.

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Participation as a Rural site

• Limited number of staff

• Difficult at times to free up staff to do module work

• Ripple effect – all departments are impacted immediately

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Benefits • With each success,

momentum grows and at times you may even have to apply the brakes to slow down the processes.

• Staff are actively

involved in problem solving

• Staff and patient

satisfaction

• Save time and money

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QUESTIONS?