Connected Thinking Blog - NACHRI Conferences

Keep Those Patients Moving - streamlining flow and eliminating waste

In a shared presentation, staff from Children’s Specialized Hospital, Mountainside, NJ, and Banner Children’s Hospital at Banner Desert Medical Center, Mesa, AZ, shared their experiences in streamlining patient flow and staff flow to see radical cost savings and patient satisfaction improvement. 

Michael Marranca from Children's Specialized Hospital closed their presentation with a quote from Shigeo Shingo of Toyota: "The most dangerous kind of waste is the waste we do not recognize." This idea was epitomized in the presentations, where careful, critical analyses of clinical flow showed numerous, unexpected areas for improvement.

The slides and session overview on the NACHRI site paint a detailed picture of challenges, findings and results, which saved hundreds of thousands of dollars, reduced wasted clinical time more than 50 percent, and made great leaps in Press Ganey patient satisfaction scores.

Check out the Children's Specialized Hospital presentation, Our Patients Shared, We Cared & Dared to Be Lean.

Check out the Banner Children's Hospital presentation, Keep Those Patients Moving!

Family-Centered Handoffs are Good for Patients and Nurses

Paula Forsythe and Joyce Deptola of Rainbow Babies and Children's Hospital in Cleveland, OH discussed how nursing staff handoffs with the patient and family and utilizing a standard format improved both family satisfaction and quality of communication. They described the PATIENT acronym used for the hand-off:
P: Patient data (name, age, presenting problem, diagnosis, history to date); Patient Profile
A:  Assessment of systems (significant findings); Assessment of current status (DNR, allergies)
T:  Tests (labs, results, outstanding tests, procedures)
I:  Interdisciplinary Plan of Care (overview & patient response); Interventions and medications
E:  Education, Emotional Needs
N:  Nurse’s focus for the next shift
T:  Timetable for discharge;  Discharge Plan
Variations of the hand-off structure have been expanded to other departments and care-providers. Process managers will continue to monitor compliance with the changes and outcomes in quality and satisfaction

Paula Dycos of Le Bonheur Children's Medical Center in Memphis, TN described their change to family-centered hand-offs at shift change in an effort to reduce both family and staff stress and dissatisfaction with care. After implementation of family-centered rounding, parent surveys showed increased satisfaction, particularly with the issues of: How well did the nurse keep you informed about your child’s treatment and/or condition? And, Did the staff on your nursing unit show respect for you and your child’s needs?  Nurse staff satisfaction with their work also improved, with nurses feeling much more informed and confident in providing care and wasting less time in report. Process managers reviewed the impact of the change on overtime costs and found a significant decrease in overtime hours after implementation of family-centered handoffs. Work continues on spreading these changes to other services and other patient hand-offs, such as leaving the floor for studies or therapy.

A good partnership with physicians is essential to meeting a quality agenda

Pamela Duncan and Kathy Jost of The Children's Hospital at Oklahoma University Medical Center in Oklahoma City, OK discussed how a little-used and attended physician’s committee on operations was transformed into an active and effective Shared Quality Committee. The IHI Framework for engaging physicians in a shared quality agenda was central to reengaging and refocusing physicians with the work of this committee. The hospital committed analyst, communication, and other resources to this effort believing that return on investment would be realized through improvements in care. The hospital and physicians worked together to identify improvement priorities through an objective and rational scoring system. The Quality Analyst was important in guiding, supporting, and reminding the teams to stay on task. Physician and nurse champions reported progress regularly and shared this information with their staffs, effectively reinforcing process improvements. Important lessons included targeting a process that is of a manageable size and ensuring you have data to track progress. Improvement efforts in many departments led to better patient outcomes and benefits to the hospital through decreased length of stay, reduced codes outside of the ICU, and less complications from treatments.

Craig Cordola and Amber McKenzie of Children's Memorial Hermann Hospital Houston, TX discussed how a new quality infrastructure was created to drive quality improvements. These changes included hiring a physician-in-chief and surgeon-in-chief, bringing a chief of infection control on board, and developing new committee structures to support quality initiatives. The quality structure also included building the data collection capabilities, establishing a relationship with NACHRI’s Case Mix Index database for external benchmarking, and developing a “Filter Process” to review all reported variances. Efforts have been successful in reducing morbidity and mortality among patients. The hospital, in conjunction with the medical school, has developed a Physician Quality and Safety Academy to advance expertise in the science of improvement and assure medical staff involvement in defining and attaining quality and safety goals. A similar effort to identify and train top nursing talent in quality and safety improvement has recently been launched.

Meeting the psychosocial needs of patients and families is essential to achieving quality

This presentation was a combined effort of three teams. The presentations were linked by the importance of meeting the psychosocial needs of families to improve the safety and quality of care.

Barbara Gursky and Kari Mastro of The Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Univ. Hospital in New Brunswick, NJ discussed the role of child life specialists in improving the quality of pediatric ED services and increasing parent satisfaction with those services. Interventions provided by professional child life specialists resulted in significantly less distress in children experiencing laceration repair and much improved parent satisfaction in services provided. In addition to improving the outcome of care, these improvements have potential direct financial benefits for the hospital. Greater satisfaction with services is expected to increase the likelihood parents will recommend the hospital to other and return to the hospital, if their child needs care in the future.

Kathryn Shamszad and Theresa Edmunds of Texas Children's Hospital in Houston, TX presented their efforts in revising the ICU visitation policy into a truly evidence-based practice. They showed how family-centered practices improved patient and family outcomes, while posing no additional risks to the care of the pediatric ICU patient. A key concern was risk of infection, a concern that was found to be unnecessary. The resulting policy change allowed siblings as young as 11 to visit without accompaniment by a Child Life Specialist – thus expanding the opportunities for siblings and families to support their loved one. The Child Life team hopes to use their ongoing experience with this new policy to add to the evidence base on the sibling visitation

Deborah Chasco of R.E. Thomason Hospital in El Paso, TX discussed how family satisfaction with patient-centered care is an important guide to achieving process improvements. She described how increased parent satisfaction with blood draw procedures was associated with lower contamination rates.  Ms. Chasco reviewed the Plan Do Study Act process used to identify, implement, and review the success of the interventions directed to improving blood draw process – a benefit to patients, families, and the hospital.

Residents can be an important part of advancing safety

Anu Sobramony and Lindsey Tilt of Morgan Stanley Children’s Hospital of NewYork–Presbyterian in New York, NY presented how teaching hospitals can effectively integrate residents in quality and safety efforts.  Resident involvement can benefit the institution today through the observations and efforts of these front line providers as well as develop knowledgeable advocates for safety and quality for the future. The activities also help residents meet ACGME requirements for safety improvement training. They discussed bringing residents into the process through the voluntary MERS process – resulting in increased reporting, greater appreciation and knowledge by residents of safety efforts, and initiation of several efforts to improve care processes identified through case review.

Drs. Subramony and Tilt emphasized the use of current cases and the importance of closing the loop with residents, nurses, and other staff entering MERS reports. Discussion with attendees resulted in ideas to include medical students in MERS activities and to ensure communication of resident activities to other safety efforts within the institution to prevent redundancy of efforts.

Reporting Quality: Individualize the Message to the Intended Audience

Anne J. Wright and Patricia Mullan of Alfred I. duPont Children's Hospital in Wilmington, DE and Keith Mandel and James Papp of Cincinnati Children's Hospital Medical Center in Cincinnati, OH advised attendees on the importance of defining the target audience for pediatric quality reporting and its particular informational needs.

Ms. Wright and Ms. Mullan discussed the trend for public transparency and how to develop a rational approach to meeting that need. They described how consumers learn about health care quality and act upon that information.

Dr. Mandel and Mr. Papp detailed pediatric-specific issues and challenges associated with public reporting to regulators and payers. They explained a process used by the network of children’s hospitals in Ohio for responding to state-level public reporting initiatives and discussed strategies to proactively influence public reporting initiatives.

Advances in Bedside Care Prevent Adverse Events

Susan Stacey of Sacred Heart Children’s Hospital in Spokane, WA and Mari Akre and Mary Erickson of Children’s Hospitals and Clinics of Minnesota in Minneapolis, MN described their efforts in reducing ventilator associated pneumonia (VAP) and implementing the Pediatric Early Warning Score (PEWS).

Ms. Stacey stressed the importance of a multidisciplinary team approach to preventing VAP, described the specific practice changes that reduce ventilator-associated pneumonias and explained how to sustain successful practice changes.

Ms. Akre and Ms. Erickson showed how PEWS can be utilized to identify early signs of clinical deterioration and prevent many codes outside of the PICU and offered recommendations on how to implement the system among clinical staff.

Children's Hospitals Can Lead the National Quality Agenda

Quality of health care is a hot topic in the national health reform discussion. Recent federal legislation specifically addresses several quality issues and includes funding for quality and health IT activities.

Dr. Marlene Miller of NACHRI and Johns Hopkins University offered an overview of the health care quality discussion among national policymakers and stressed the opportunity for children’s hospitals as a group to be the leading example of quality in the U.S.

 

She provided the NACHRI-coordinated CA-BSI collaboratives as relevant, timely, and highly effective examples of quality improvement efforts. The shared efforts of the over 60 patient care units in over 50 children’s hospitals make the collaborative quality improvement model successful. In addition to achieving considerable improvements in reducing CA-BSI rates (in just 2 years, Phase I hospitals have prevented 632 line infections, saves more than 75 lives, and reduced potential health care costs by $22 million), collaborative hospitals are identifying evidence-based best practice and spreading the safety culture throughout their institutions.

Dr. Miller described next steps for the current CA-BSI collaboratives and discussed expansion of the project to an additional group of 30 hospitals. She also announced plans for new collaboratives of children’s hospitals to begin work in the areas of hematology-oncology and emergency medicine.

Family Advisory Councils Are an Important Part of Quality

Ann O’Connor and Philip Graham of Morgan Stanley Children’s Hospital of New-York Presbyterian in New York, NYdescribed the important role of family advisory council’s (FAC) in developing and sustaining quality improvement efforts. They discussed an effective model for communication between the FAC and hospital staff leaders of safety and quality improvement efforts. Ms. O’Connor and Dr. Graham shared several examples of how FAC members helped hospital staff initiate and communicate to parents of patients valuable improvement initiatives. These included hand hygiene, medication safety, and family rounding. Family member contributions to improvement efforts in the hospital are well-received and participation has expanded to additional hospital committees.

Common Cause Analysis Puts Logic into Quality Improvement Initiatives

Anne Marie Brown and James Steven of Children’s Hospital of Philadelphia described how quality improvement activities, such as root cause analysis (RCA), can potentially overwhelm an organization with indicated action items and unclear organizational priorities. They showed how Common Cause Analysis (CCA) can be used to focus on the most important RCA findings and appropriately prioritize them for organizational planning. The rational CCA process can help hospitals develop effective improvements, include sufficient funding in the planning process and monitor the success of efforts at a leadership level.