Module 2:

Implementing QBPs On Your Unit

Quality Based Procedures (QBPs)

Pathway Improvement Program

Provide Reference As Part of Training

• Included in the Implementation Binder:

• Overview and Case for Change Document

• Standard Work Instructions Document

• Frequently Asked Questions (FAQ)

• Hard Copies of the Bundles – Order Set

– Clinical Pathway

– Patient Experience Pathway Brochure

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Reminders from Module 1 Overview

• WRH is launching an innovative, creative and exciting new program to improve patient care as part of the QBP Pathway Improvement Program

• The first 5 conditions are: Stroke, CHF, Hip Fracture, COPD, and Pneumonia

• Pathway Program diagnoses will have 3 components: Order Set, Clinical Pathway, and Patient Experience Pathway

• Care practices at the bedside will be supported by these documents: including integration with Shift to Shift, Care Rounds, White Boards, conversations with patients and families, and conversations with physicians

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Order Set Clinical Pathway Patient Experience My Care Journey

Pathway Improvement Bundle

How do I get these documents?

• Available from Print Shop Storefront as a bundle with the following documents all clipped together: – Order Set

– Clinical Pathway

– Patient Experience Pathway Booklet

• All documents can be ordered separately if needed by your Unit Clerk through the Print Shop Storefront

• QBPs may have additional documentation included in the bundle to support specific assessments (i.e. Stroke best practices)

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The Patient Journey

Order Sets Physicians – Medical orders

Clinical Pathways Care Teams – Treatment and discharge planning

Patient Experience Pathway Patient and family members

What are Order Sets?

• Evidence-based, conveniently grouped, physician-led medical orders that standardize diagnosis and treatment

• They follow recommended best practices to improve quality of care while reducing clinical variation

7 Order Set

What is different?

• Previously, there were multiple versions of Order Sets for each campus; New versions are updated based on best practice and standardized across campuses

• Consists of 2 parts: Transitional and Inpatient Phase

8 Order Set

What is different?

• Based on the primary admitting diagnosis, the Pathway Improvement Bundle is initiated at the point of admission

• Transitional Orders are started in the ED and signed by the ED Physician, in consultation with the MRP

• Admitting Physician (MRP) to:

– Check the box and sign each Transitional Phase page indicating that he/she will continue with the management of the patient

– Continue with Inpatient Phase Orders

9 Order Set

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The Patient Journey

Order Sets Physicians – Medical orders

Clinical Pathways Care Teams – Treatment and discharge planning

Patient Experience Pathway Patient and family members

What are Clinical Pathways?

• Provides a guide to care, suggesting specific interventions that should be considered and outcomes that should be achieved along the patient journey towards discharge

• Includes 3 main components:

1. Interventions

2. Outcomes

3. Discharge Criteria

11 Clinical Pathway

Main Components of the Clinical Pathway

1. Interventions: – A reference of what needs to be done for the patient on each day

– Aligns to the Order Set

2. Outcomes: – What the patient is expected to achieve or have done each day

– Outcomes are to be assessed and documented every shift

3. Discharge Criteria: – Assessed daily before Care Rounds in order to discuss criteria not

achieved (barriers to discharge)

– When all criteria have been achieved, MRP is to be notified to consider discharge

12 Clinical Pathway

Interventions & Outcome Pages

• Broken down by days

• Initiated on day of admission (Admission Day – Day 0)

• Will be initiated by the ED staff if patient remains in the ED greater than 4 hours after admission

13 Clinical Pathway

Interventions & Outcome Pages

• Every shift, interventions reviewed and outcomes documented as achieved or not achieved

Initials = Outcome has been achieved

Star (*) With Initials = Outcome has been assessed but NOT achieved; Requires further documentation in the nurse’s notes; Action is required

• There is a column on the right side for each shift; Remember to add the shift start and stop to the top of the column

14 Clinical Pathway

Discharge Criteria Page

• The last page of the Clinical Pathway has the diagnosis specific discharge criteria

• If all discharge criteria are achieved prior to the end of the pathway, discharge may occur sooner

• Once all achieved, MRP is to be notified to consider discharge

• Additional “blank” documents can be found as an additional document in the Order Sets Library or ordered from the Print Shop Storefront

15 Clinical Pathway

Changing practices at the bedside

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Shift To Shift

Care Rounds

White Boards

Conversations with Patients and Families

Collaboration with Physicians

Changing practices at the bedside

• Care Rounds: Bring the Clinical Pathway to the Care Rounds in addition to the Patient Summary Tool

– Using the Clinical Pathway as a support, the discussion is focused on barriers to discharge

– Outstanding discharge criteria and concerns are to be escalated at Care Rounds for support and discussion

17 Clinical Pathway

Changing practices at the bedside

• Shift to Shift: Use the Clinical Pathway Discharge Criteria to review barriers to the patient progressing towards discharge and follow-up actions that might be required

• In-Room White Boards: Use the Clinical Pathway and the “My Care Journey” booklet to update the whiteboard with Today’s Plan of Care and EDD

• Conversations with Patients and Families: Use the Discharge Criteria to guide conversations and set expectations about length of stay starting at admission

• Collaboration with Physicians: Unmet discharge criteria is used to support discussions with the MRP

18 Clinical Pathway

Calculating Expected Date of Discharge

• The Expected or Estimated Day of Discharge (EDD) is based on the average patient

• Patients may go home before or after this date depending on condition and acuity

• How to calculate: – Do not count Day of Admission (This is Day 0)

– Count up using the Expected Length of Stay (ELOS)

– Example:

Admitted July 1 (Day 0)

Pathway ELOS = 5 days

EDD = July 6

19 Clinical Pathway

Escalating Barriers to Discharge

• The patient’s nurse is empowered to resolve outstanding discharge barriers (i.e. labs, DI, allied health, consults, etc.) and escalate as needed

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Staff to Staff Front-line staff should attempt to resolve with the

supporting department

Staff to Escalate to Operations Manager* The Ops Manager will attempt to move the patient forward

in the care plan by removing barriers

Operations Manager to Director

*Escalate to the After Hours Manager when applicable

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The Patient Journey

Order Sets Physicians – Medical orders

Clinical Pathways Care Teams – Treatment and discharge planning

Patient Experience Pathway Patient and family members

What are Patient Experience Pathways?

• Outlines the Clinical Pathway in patient friendly language

• Works to inform and set clear expectations regarding each day of the patient’s stay

• Completes the link to translate the care journey in a way that patients and families can understand

• Complements the conversations care teams are already having with patients and families

22 Patient Pathway

What are Patient Experience Pathways?

• Launching as My Care Journey, it consists of 3 components:

1. Patient Booklet: A daily guide for patients; Outlines the expected length of stay and steps patients can take to manage their health and prepare for discharge

2. Website: An internet site with supporting information about their condition and links to additional resources

3. Mobile App: An innovative mobile-app to share information with family members away from the bedside – A first in Canada to focus on what to expect during the hospital stay

• Supported by Conversations: Existing conversations already happening are supported by new tools

23 Patient Pathway

My Care Journey: Booklet

• Bright and engaging focus on expectations towards discharge

• Aligns with the Clinical Pathway, but in patient friendly language

• To be given and explained to the patient and family members soon after the point of admission or when arriving on the unit

24 Patient Pathway

My Care Journey: Website

• WRHCareJourney.ca

• Includes electronic versions of the brochure, as well as the text versions in French, Arabic, Spanish and Italian that can be printed on your unit

• Includes additional information about their condition and links to other resources to help manage their health

25 Patient Pathway

My Care Journey: Phone App

• Innovative mobile-app to share information with family members; Includes similar content as the booklet and website

• Downloaded from the iTunes App Store or Google Play Store

26 Patient Pathway

Changing practices at the bedside Conversations with patients and families • Give the booklet to the patient/family soon after admission;

Use professional judgement if limited capacity and no family

• When giving booklet to the family, tell the patient and family:

– This is a guide to what they can expect during their stay

– Their care team will keep them informed during their stay

– Depending on the condition, the patient may go home sooner

• Follow-up daily to see if there are questions about the journey, discharge readiness, or to provide updates about their plan

• Remember that the information provided is based on the typical patient journey and you know more about the specifics of each patient’s condition

27 Patient Pathway

Where can I get more information?

• Standard Work Instructions

• Overview of Changes

• Frequently Asked Questions

• WRHow.ca

• Clinical Practice Manager and/or Operations Manager

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