MLC Annual Healthcare Lean Symposium

October 10 2014

Brian Vander Weele Senior Process Engineer

Leveraging Lean Process Improvement

Methodology to Enhance Patientrsquos

End of Life Care

Spectrum Health Hospitals at a Glance

Not-for-profit health system based in West Michigan

Comprised of 11 hospitals (over 1370 licensed beds)

Includes physician group totaling more than 1000 providers

Priority Health Plan with over 575000 members

Over 21000 employees

Background

In further analyzing inpatient mortality rates the Quality

Department discovered the following

Chart reviews indicated that Spectrum was not consistently

identifying patients with end stage disease or appropriately

facilitating discussions about treatment options

Inpatient mortality data indicated

Average age was 71 years old

27 of inpatient deaths had transfered to Inpatient Hospice

67 of inpatient deaths had end stage disease

Average of inpatient days in 6 months prior to death was 125

End-of-Life ldquoWishesrdquo Care

What Patients Want

Majority of Americans prefer to die at home

(Hays et al 2001 Gallup 2000)

Pain-Free Passing

What Patients Get

335 die at home (2009 Teno et al 2013)

Patients continue to die in pain

(Meier 2006)

The Dilemma Challenge

Providing What People Need (or Want) Is Often

Different From What We Naturally Want To Do

This is especially true in healthcare as it relates to end of life

care ndash hence the cultural clash of ldquobias to treatrdquo vs

considering patientfamilyrsquos end of life wishes

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

Spectrum Health Hospitals at a Glance

Not-for-profit health system based in West Michigan

Comprised of 11 hospitals (over 1370 licensed beds)

Includes physician group totaling more than 1000 providers

Priority Health Plan with over 575000 members

Over 21000 employees

Background

In further analyzing inpatient mortality rates the Quality

Department discovered the following

Chart reviews indicated that Spectrum was not consistently

identifying patients with end stage disease or appropriately

facilitating discussions about treatment options

Inpatient mortality data indicated

Average age was 71 years old

27 of inpatient deaths had transfered to Inpatient Hospice

67 of inpatient deaths had end stage disease

Average of inpatient days in 6 months prior to death was 125

End-of-Life ldquoWishesrdquo Care

What Patients Want

Majority of Americans prefer to die at home

(Hays et al 2001 Gallup 2000)

Pain-Free Passing

What Patients Get

335 die at home (2009 Teno et al 2013)

Patients continue to die in pain

(Meier 2006)

The Dilemma Challenge

Providing What People Need (or Want) Is Often

Different From What We Naturally Want To Do

This is especially true in healthcare as it relates to end of life

care ndash hence the cultural clash of ldquobias to treatrdquo vs

considering patientfamilyrsquos end of life wishes

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

Background

In further analyzing inpatient mortality rates the Quality

Department discovered the following

Chart reviews indicated that Spectrum was not consistently

identifying patients with end stage disease or appropriately

facilitating discussions about treatment options

Inpatient mortality data indicated

Average age was 71 years old

27 of inpatient deaths had transfered to Inpatient Hospice

67 of inpatient deaths had end stage disease

Average of inpatient days in 6 months prior to death was 125

End-of-Life ldquoWishesrdquo Care

What Patients Want

Majority of Americans prefer to die at home

(Hays et al 2001 Gallup 2000)

Pain-Free Passing

What Patients Get

335 die at home (2009 Teno et al 2013)

Patients continue to die in pain

(Meier 2006)

The Dilemma Challenge

Providing What People Need (or Want) Is Often

Different From What We Naturally Want To Do

This is especially true in healthcare as it relates to end of life

care ndash hence the cultural clash of ldquobias to treatrdquo vs

considering patientfamilyrsquos end of life wishes

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

End-of-Life ldquoWishesrdquo Care

What Patients Want

Majority of Americans prefer to die at home

(Hays et al 2001 Gallup 2000)

Pain-Free Passing

What Patients Get

335 die at home (2009 Teno et al 2013)

Patients continue to die in pain

(Meier 2006)

The Dilemma Challenge

Providing What People Need (or Want) Is Often

Different From What We Naturally Want To Do

This is especially true in healthcare as it relates to end of life

care ndash hence the cultural clash of ldquobias to treatrdquo vs

considering patientfamilyrsquos end of life wishes

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

The Dilemma Challenge

Providing What People Need (or Want) Is Often

Different From What We Naturally Want To Do

This is especially true in healthcare as it relates to end of life

care ndash hence the cultural clash of ldquobias to treatrdquo vs

considering patientfamilyrsquos end of life wishes

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

How did Spectrum Health Approach This

Used a structured approach known as Value Stream

Analysis to identify improvement opportunities

Included patient and family advocates in our workshops

Developed a process for identifying patients with chronic

life-limiting illness that might benefit from an end of life

conversation about treatment options

By trialing improvement ideas ndash and changing the culture

one patient one physician at a time

Utilized Palliative Care to assist patients and families to

understand options and define their wishes

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

Value Stream Analysis Approach

Based on lean thinking and the Toyota Production System

Value must be specified from the patientrsquos point of view

Focuses on making it better not perfect

Donrsquot Delay - A 50 solution today is better than an

85 solution six months from now

Value Stream ndash flow of all activities or

processes that provide care to the patient

Value Stream Analysis ndash structured approach

for planning and linking improvements

together within the value stream

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Steering Team

Responsibilities

Governance structure to manage improvement

Determine Areas of Focus (VS Vision)

Establish TargetsMeasurement Systems

Remove Organizational Barriers

Create Accountability and Sustainability

Leadership Standard Work Auditing

End of Life Care Steering Team

Membership included Executive Sponsor and Physician

Champion a Process Owner Process Improvement

Engineer and other key stakeholders (6-12 members)

Reviewed status of key metrics progress on previous

improvement RIEsProjects planning for future RIEs etc

Weekly meetings

Monthly review of

Mission Control

Board

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

A3 Thinking

A structured cycle of improvement

Framework for organized thinking

Confirmed State

Experiments

Hypothesis ndash

ifhellipthenhellip

Gap Analysis

Future State

Current State

Business Case

Lessons Learned

Completion Plan

Can be used for

Strategy Deployment

Value Stream

Analysis (VSA)

Rapid Improvement

Events (RIE)

Problem Solving

Personal

Development

9 block approach

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Steering Team

Responsibilities

Governance structure to manage improvement

Determine Areas of Focus (VS Vision)

Establish TargetsMeasurement Systems

Remove Organizational Barriers

Create Accountability and Sustainability

Leadership Standard Work Auditing

End of Life Care Steering Team

Membership included Executive Sponsor and Physician

Champion a Process Owner Process Improvement

Engineer and other key stakeholders (6-12 members)

Reviewed status of key metrics progress on previous

improvement RIEsProjects planning for future RIEs etc

Weekly meetings

Monthly review of

Mission Control

Board

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

A3 Thinking

A structured cycle of improvement

Framework for organized thinking

Confirmed State

Experiments

Hypothesis ndash

ifhellipthenhellip

Gap Analysis

Future State

Current State

Business Case

Lessons Learned

Completion Plan

Can be used for

Strategy Deployment

Value Stream

Analysis (VSA)

Rapid Improvement

Events (RIE)

Problem Solving

Personal

Development

9 block approach

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life Care Steering Team

Membership included Executive Sponsor and Physician

Champion a Process Owner Process Improvement

Engineer and other key stakeholders (6-12 members)

Reviewed status of key metrics progress on previous

improvement RIEsProjects planning for future RIEs etc

Weekly meetings

Monthly review of

Mission Control

Board

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

A3 Thinking

A structured cycle of improvement

Framework for organized thinking

Confirmed State

Experiments

Hypothesis ndash

ifhellipthenhellip

Gap Analysis

Future State

Current State

Business Case

Lessons Learned

Completion Plan

Can be used for

Strategy Deployment

Value Stream

Analysis (VSA)

Rapid Improvement

Events (RIE)

Problem Solving

Personal

Development

9 block approach

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

A3 Thinking

A structured cycle of improvement

Framework for organized thinking

Confirmed State

Experiments

Hypothesis ndash

ifhellipthenhellip

Gap Analysis

Future State

Current State

Business Case

Lessons Learned

Completion Plan

Can be used for

Strategy Deployment

Value Stream

Analysis (VSA)

Rapid Improvement

Events (RIE)

Problem Solving

Personal

Development

9 block approach

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

A3 Thinking

A structured cycle of improvement

Framework for organized thinking

Confirmed State

Experiments

Hypothesis ndash

ifhellipthenhellip

Gap Analysis

Future State

Current State

Business Case

Lessons Learned

Completion Plan

Can be used for

Strategy Deployment

Value Stream

Analysis (VSA)

Rapid Improvement

Events (RIE)

Problem Solving

Personal

Development

9 block approach

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Improvement Process Centers Around ldquoWhat Ifrdquo

What if

We helped patients identify what their wishes are

Instead of Automatically assuming that patients and families

want full treatment ndash after all they showed up at the

hospital right

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Workshop

Typically a 3 day planning event ndash follows the A3 format

Day 1 ndash Analyze the Current State

Day 2 ndash Define the Ideal and Future State

Day 3 ndash Develop Action Plan and A3rsquos

Main deliverable is a prioritized Action

Plan for the next 12 months

BOX 7 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

RIE

PR

OJ

EC

TS

Just-

Do-It

Just-

Stop-It

See Action Plan for

details

Improve the Technology RIE

Provide better end of life care Discharge Instructions RIE

Project 1 - Pilot identifying patients in ED using trigger tool amp either dc-ing pt from ED with hospice referral or placing pts in Obs Unit

Project 2 - Pilot Early Palliative Care consult I-rounds on Obsevation Unit (2W)

Project 3 - Pilot Early Palliative Care consult I-rounds on 4W - Including Direct Admits

Provide appropriate education for ED Physicians Hospitalists Residents RNs and staff based on EBC

Project 4 - Pilot Early Palliative Care consult I-rounds on Surgical ICU unit

Evaluateopportunities to implement a pre-screening process with SH Direct

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Participants

Patient Family Advisory Council Member

Fresh Eyes

Value Stream Owner

Executive Sponsor

Physician ndash Palliative Care

Physician ndash Hospitalist Group

Physician ndash Acute Care

Director ndash Emergency Services

Nurse Manager ndash Observation Unit

Supervisor ndash Billing

Representative from Hospice

Director of Nursing Practice

Manager of Advance Care Planning

Quality Data Analyst

Senior Analyst ndash Compliance

Manager ndash Coding

Clinical Ethicist

Process Engineer

PI Coach

Sensei

1013 1113 1213 114 214 314 414 514

RIEs

Pro

ject

s

Just

Do-Its

(or

Stop-

Its)

Indicates Complete Indicates Future Plan

EOL ACP RIE

Trigger Tool on

SCCU amp ACE units

Operationalize

AD Patient Wishes (ACESCCU)

Patient Education

upon DC (ACE)

Util ization of

CMMSW (SCCU)

Provideappropriate

education for ED Physicians Hospitalists

Residents RNs and staff

TRIGGER

TOOL PILOT(Nov 12 -Dec 12)

ED 4-West

Obs Unit

Improve the

Technology

Electronic Trigger

Tool Notification of prev PC consult

Pilot the Trigger Tool

at United

Hopital

Develop EOL

Dashboard

Education Plan for Physicians amp Staff based

on Pilot Results

Informal - ongoing)

Develop an

Overall Education Plan

w subject matter experts

(3 yr plan)

- coordinate with

Bris project timeline

Action

Plan

End of Life Care VSA Workshop (Sep 4-6 2013)

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life Care VSA Workshop (Sep 4-6 2013)

Business Case Chart review of recent

mortalities indicates that Spectrum

Health is not consistently identifying

patients with end stage disease or

appropriately facilitating discussions

about treatment options

Ideal State

Future State

Provide best practice evidence based

end of life care as described by the

Gundersen Lutheran model IHI etc

Provide appropriate tools

1) To identify appropriate patients

2) For caregivers to feel comfortable to

have the conversations regarding

end of life treatment plans

3) To document those treatment plans

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life Care VSA Workshop (Sep 4-6 2013)

If we Identify patients

who are at end of life

earlier in our process and

provide appropriate

resources for decision-

making

Then we Have a

greater chance of providing

the type of end of life care

that the patient and family

desires

Box 5 Hypothesis

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Trigger Tool Pilot (Nov 12 ndash Dec 12 2013)

Improving Recognition amp Care of Patients with End-Stage

or Life-Limiting Illness Who are Appropriate for a

Palliative Care Consult to Discuss Treatment Options

No simple quick tools in existence yet

so Spectrum Health developed our own

ldquotrigger toolrdquo

Piloted the form in ED and a MedSurg

unit supported by Hospitalist Group

Patients 65 and older with one or more

EDinpatient encounters in past 6

months eligible for Pilot

Follow guidelines on form

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Results of the Trigger Tool Pilot

411 Trigger Tool Forms Initiated

6 Palliative Care consults generated

Was this a failure

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

First Patient in the Pilot

85 yr old woman with metastatic kidney disease admitted

to observation for dehydration failure to thrive

Palliative Care consulted saw patient win 12 hrs of arrival

on the unit Had a family meeting - worked through issues

Patient sent home with hospice that evening

Success

Had been significant discord between patient and family

Able to facilitate a conversation in the Observation Unit

Patient got what she wantedneeded without needing to be

admitted to the hospital

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Another Success Story

77 year old woman presented to the emergency department with

widespread kidney cancer dehydration and poor nutrition

Using the new trigger tool the ED notified the palliative care team

The team scheduled a family meeting where the patientrsquos goals

wishes and preferences for care were discussed

The conversation resulted in the patient amp family mutually deciding

the best course of care was to enroll the patient in SH Hospice

Later that evening she returned to her home and received

appropriate supportive end of life care

Had this patient not been identified she would have been hospitalized

and may have undergone significantly more aggressive care and suffered

a long hospitalization inconsistent with her wishes

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Challenges Encountered During the Pilot

Societal norms related to death and dying plus physician

and healthcare organizational culture are our biggest

barriers ndash much misunderstanding inconsistent language

etc

Tendency to jump to treatment rather than evaluating

frailty

Maybe the ED isnrsquot the best place to begin to change the

bias to treat culture ndash admitting services

Did we place to much emphasis on the physician to

recognize these end of life patients ndash whole care team

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Structure for Improvement

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Rapid Improvement Event (RIE)

Typically a 4 day event (follow A3 format)

Day 1 ndash Analyze the Current State

Day 2 ndash Determine Future State amp Hypotheses

Day 3 ndash Run Experiments

Day 4 ndash Develop Standard Work

Small team of people focused on improving a part of a

value stream

Begin to change the culture so that

ldquochanges can happen dailyrdquo

Design test amp implement improvements (results) by the

end of the activity (week)

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life ACP RIE (Jan27-30 2014)

Business Case Chart review of

recent mortalities indicates that

SH is not consistently asking or

operationalizing the

patientfamily wishes for

treatment of patients who are

admitted with an Advance

Directive or who have a chronic

life-limiting illness Patients are

offered treatment before the

clinician assesses what the

patientrsquos wishes goals and

preferences are rather than

offering all available options

Scope Patients admitted to

SCCU and ACE Units

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life ACP RIE (Jan27-30 2014)

Future State

Spectrum Health will have the following in place for patients

with chronic life-limiting illness

Method for identifying these patients (at admission or during

daily assessments) that would benefit from a Palliative Care

Consult earlier in the patientrsquos stay

Provide Education and DC Instructions regarding importance

of ADDPOAH amp life-limiting illness

Standard Work documenting Care Plans with meet Advance

Directives and patient wishes ndash that readily transfer to PCP

and provide alerts for future ED visits and admissions

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Trigger Tool

Early identification of

patients who could

benefit from Palliative

Care consult

Good opportunity to

discuss and

document patientrsquos

wishes

Standard Work

Interdisciplinary

Rounds

End of Life ACP RIE ndash Experiments SCCU

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Trigger Tool ndash similar to SCCU

Discharge Education

Standard Work for providing

patients with resources related

to ADamp ACP upon DC

Reinforce importance of having

ADDPOAH

Standard template for

Discharge Progress Note ndash to

carry over to future encounters

Initiate MDI

End of Life ACP RIE ndash Experiments ACE

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

1 appropriate Intervention for ptfamily

Trigger Tool used for 7 patients in SCCU

ndash 2 resulted in Palliative Care Consults

Care ManagerMSW attended 7 of 7

patients on SCCU rounds

6 of 11 patients ldquotriggeredrdquo for PC

consult during I-Rounds on ACE unit

ACE Unit able to provide AD packet to

patient upon discharge

1 opportunity for standard template RN

discharge note regarding patient wishes

Develop an

appropriate process

to fully understand

the patientrsquos wishes

Provide care

according to the

patientrsquos wishes

End of Life ACP RIE - Day 3 Results

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Before and After (RIE Patient Story)

83 year old woman admitted 10 days prior w Sepsis ndash intubated for several days prior

Was extubated for a day and now declining again ndash needed re-intubation within hours

During RIE Rounding ldquoexperimentrdquo ndash Palliative Care consulted amp Care Mgmt notified

son (DPOAH)

Husband and son indicated that patient previously expressed that she did not want to

be on ldquolife supportrdquo No clear understanding of choices presented to them

Once husband and son understood what being put back on the ventilator really meant

ndash they elected comfort care and did not re-intubate the patient

Hospice there within a couple of hours

BEFORE

In the confusion of medical terminology ndash

patient would have been re-intubated

Patient would likely have been on the

ventilator for many days (in hospital or

LTC facility) contrary to her stated wishes

Eventually patientrsquos family would have to

decide to take patient off the ventilator

AFTER

Re-addressing goals in a timely fashion

allowed the ICU team to better

understand the patientrsquos wishes

Patient passed away peacefully that night

with family at the bedside

Intervention allowed team to support the

patientrsquos wishes support the family and

ensure a peaceful death

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

End of Life ACP RIE (Jan27-30 2014)

Before Provider Focus ndash ldquoBias to Treatrdquo

After Patient Focus (PFAC)

Clear description of options (What are my choices)

More education on importance of having ADDPOAH for

patients and family

Get Patient Education and DC Instructions to patient amp

family earlier ndash not when going out the door at discharge

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

VSA Structure for Improvement (Sustain)

Value

Stream

Analysis

Workshop Develop

Prioritized

Action

Plan 4-day

Rapid

Improvement

Events (RIE)

Standard

Work

VSA Steering Team

Managing

For Daily

Improvement

(MDI)

Kamishibai

Audit

Process

A3 Thinking

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Sustaining the Improvements ndash VSA RIE

Impro

ve

men

t

Gains

Standard Work

MDI (Managing for Daily

Improvement)

Kamishibai Audits

Leadership

Standard Work

Time

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

The currently known best method to perform the work

A living document

Standard Work

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Managing for Daily Improvement (MDI)

MDI is a system for managing and sustaining process

improvement initiatives

Major Components of MDI

Visual Management Boards

Performance Tracking

Daily Huddles

Daily Problem Solving

Daily Assessments

Daily Gemba Walks

Daily Standard Work for all Roles

Can you tell in 5 seconds whatrsquos going on

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Kamishibai Auditing

Visual Audit Cards are the foundation

of the Kamishibai System

Cue cards for auditing a process

Ensure that a new process is routinely followed (accountability)

Can be used hourly daily or weekly

Audits need to be short (lt 5 minutes)

Audits need to be valuable ndash critical few vs important many

Fostering a culture that takes real time corrective action

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Kamishibai Audit Board

Used as simple

and effective

visual control in

performing daily

process audits amp

assessments of

Standard Work

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Audit Question(s)

Audit Details

Corrective Action Details

Name of Audit

Instructions

Audit Cards

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Ongoing Results ndash Palliative Care Consults

Jul 13 Aug Sep Oct Nov Dec Jan 14 Feb Mar Apr May Jun Jul Aug

BW 94 100 114 89 98 108 100 90 109 98 140 125 125

BL 20 23 32 20 27 19 23 21 28 42 21

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

Co

nsu

lts P

er

Mo

nth

No Pilot conducted at Blodgett

End of Pilot

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Ongoing Results ndash Admit Order to PC Order

0

5

10

15

20

25

30

35

Admit Order to PC Order - Butterworth (Days - median)

RIE 1

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Ongoing Results ndash Admit Order to PC Order

00

10

20

30

40

50

60

Admit Order to PC Order - Blodgett (Days - median)

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Ongoing Challenges ndash Countermeasures

Increase Hospitalistsrsquo

engagement amp understanding

Confusion among staff

between Palliative Care and

Hospice

Providers not comfortable

ldquohaving the conversationrdquo

Need to spread to many other

units in hospital

Paper ldquotrigger toolrdquo requires a

lot of ldquoupkeeprdquo

Have Physician leadership

round and do Lunch amp Learns

Provide better education for

staff to understand the

differences

Provide scripting for staff with

the education amp training

Follow implementation of

multidisciplinary rounding

Build an electronic ldquotrigger

toolrdquo

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Palliative Care The Right Thing To Do

Palliative care is the difference between asking ldquowhatrsquos the matterrdquo and asking ldquowhat matters mostrdquo

Meeting Patientsrsquo needs with a side-effect of improved quality of life at a lower cost which improves satisfaction

Aggressive symptom management vs curative management

Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol

Deciding how someone will spend the time they have left is not our decision to make

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Summary of Benefits

A greater number of patients and families are becoming better

informed about their end of life care options

Increased awareness about scope of service and support that

Palliative Care can offer to patients and clinical care team

Communication about patient wishes (advance directives) is

increasing among providers caring for them

Patientrsquos end of life options are presented their wishes are

discussed properly documented amp carried out by providers

Increase patientfamily satisfaction regarding end of life care

Reduce Length of Stay with earlier PCHospice consults

Reduce total cost of care with less aggressive caretreatments

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Lessons Learned

Having a structured process for working through all the issues

and ideas was very helpful and provided a quality process

This is a very personal and emotional process

This topic is very complex with lots of passionate ideas from

providers

Data and personal stories are both necessary to effectively

change the cultural bias from ldquoFix itrdquo to ldquoUnderstand and meet

the patientrsquos desiresrdquo

Must be patient focused and not cost driven ndash itrsquos all about

providing the right care at the right time per the patientrsquos

informed wishes ndash no more and no less

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements

Next Key Steps

Develop amp implement Goals of Care Form

Scan hard copy of AD into patient chart in ldquoreal timerdquo

Create electronic ldquotrigger toolrdquo

Education amp Training for Providers to become comfortable having

ldquothe conversationrdquo to provide options and obtain patientrsquos wishes

Develop method(s) to document amp communicate patient wishes

PC consults etc to next encounter patientrsquos PCP andor

Nursing Facility

Develop strategy for spreading the experimentspilots to other

inpatient units following the deployment of multi-disc rounding

Continue to develop MDI in units to sustain the improvements