primary, secondary & tertiary care

VETERANS HEALTHADMINISTRATION Sl ide 1

Clement J. Zablocki VA Medical Center

Primary,Secondary&Tertiarycare


Relationship Based Care Nursing Practice Model

• Threeuniquerelationshipsexist

• Eachisimportantandnecessary–NursetoVeteran–NursetoNurse/Others–NursetoSelf


Pilot Site – 7C

30bedmedicalsurgicalacutecareAveragelengthofstayis2.8days


What’s the Problem?


Target State Process Map

Patientadmittedto7C

Patientreceivescare

Dailyinterdisciplinarycommunicationwithpatientregardingcareanddischarge

Providerwritesdischargeorders

Orderscompletedbyvariousstaff

Patientdischargedfrom

7c


How Did it Feel for Veterans and Team?

§ Rushed§ Unplanned§ Chaotic

0102030405060708090

100

BaselineOct-Dec2015

Extentfeltreadyfordischarge

Speedofdischargeprocess

Thenurse keepingthepatient informed

Thephysciankeepingthepatient informed

Instructions forcareathome


What Were We Striving For?

§ Planned§ Organized§ Mutualagreement

0

10

20

30

40

50

60

70

80

90

100



Thenursekeepingthepatientinformed

Thephyscian

keepingthepatientinformed

Instructionsforcareathome

BaselineOct-Dec2015



Thenurse keepingthepatientinformed

Thephysciankeepingthepatient informed

Instructions forcareathome


Gap Analysis

Barriers Cause

CommunicationMinimal interdisciplinarycommunication/coordination inadvanceofdischargeday.

Complexity Lack ofdischargeplan resultsinpotentially delayeddischargerelatedtotransportation, homecaresuppliesandequipment.


Solution Approach

Ifwedothesethings…then wewillimproveVeteranSatisfaction…..

Allclinicians updateInterdisciplinaryDischargeCarePlan inElectronicMedicalRecord(CPRS).

CommunicateregularlywiththeVeteran aboutprogresstowardDischargeandtheDischargePlan

Proactivelyaddresscomplexdischarges*priortothedayofdischargetoensureallneedsaremetandthepatientknowsthefullplan.*Dischargesrequiring homecare,transport,supplies/equipment, Veteran/caregivereducation


What is The Daily Plan® VA National Center for Patient Safety ?

• Apatient-specificitineraryusedtoinformpatientsofwhattoexpecteachdayinthehospital

– Medications– Demographics– NextofKin (NOK)– Inpatientandoutpatientappointmentshttps://www.patientsafety.va.gov/professionals/onthejob/dailyplan.asp


Why Use The Daily Plan ® ?

• EncouragesVeteranand/ortheirfamilytospeakupandbeinvolvedintheircare

• Providesanopportunityforpatienteducation• Establishesaplantohelpguide/progressthecare• Facilitatesandaugmentsthedischargeplanningprocess


Things we tried and then changed…... (PDSA)

• VeteranOrientationtoTheDailyPlan®

• PreparationofTheDailyPlan®envelopes

• SurveyingPatientandstaffRN’sabouttheirsatisfactionwithTheDailyPlan®


Our Daily Plan Innovation• ModifiedtheNationalDailyPlantoinclude

– InterdisciplinaryDischargePlan(IDDCP)Notes– PertinentLabValues

• OurProcess– NursereviewsTheDailyPlanwiththeVeteraneverymorning

– Veteransareencouragedtoaskquestions

Chan

ges –

IDD

CP

Doc

umen

tatio

n


------------------ FingerStickGlucose(max5occurrences)------------------CollectionDT Specimen TestName Result Units RefRange09/07/201604:10 BLOOD FINGERSTICKGLUC 105H mg/dL 70- 9903/26/201511:30 BLOOD FINGERSTICKGLUC 120H mg/dL 70- 99

--------------- LabTestsSelected(max1occurrenceor1day)*---------------CollectionDT Specimen TestName Result Units RefRange01/06/201706:30 BLOOD WBC 5.8 K/uL 4.0- 11.001/06/201706:30 BLOOD RBC 4.36 M/uL 4.2- 5.701/06/201706:30 BLOOD HGB 11.0L g/dL 13- 1701/06/201706:30 BLOOD HCT 35.2L % 40- 5101/06/201706:30 BLOOD PLATCT 252 K/uL 130- 40001/06/201706:30 PLASMA K+ 4.0 mmol/L 3.5- 4.701/06/201706:30 PLASMA NA+ 138 mmol/L 136- 14501/06/201706:30 PLASMA CREAT 1.31H mg/dL .67- 1.1701/06/201706:30 PLASMA CA+ 8.5 mg/dl 8.5- 10.1

----------------- * MgandPT/INRincludedwhenappropriate---------------

Changes - Labs with Reference Ranges


Confirmed State Process Map

Patientadmittedto7C

TheDailyPlan(TDP)printedanddiscussedonadmission

MSAprintsTDPeachmorningat10:00AM

NursereviewsTDPwith

patienteverymorning

Patientconfirms

understandingofTDP

Patientdischargedfrom7c


7C Veteran Experience Data 2016-17 7C

Sat

isfa

ctio

n D

ata


Lessons Learned

•Communicationisessential– Interdisciplinaryteam–VeteranInput

•WhatfactorsintotheVeteranbeingreadyfordischarge?

•Whatfactorsimpactatimelydischarge?


Next Steps

• ContinuedcollaborationwithITtomakeTheDailyPlan®asuserfriendlyaspossible.

• Ongoingoutreachandeducationforclinicians(PT/OT,SW,MedicalandSurgicalResidents,hospitalists,NP’s,supportstaff,andfloats

• Takingthisinitiativehouse-wide!


• Baker,G.Ross,Fancott,C.Judd,M.O’Connor, P.(2016).Expandingpatientengagementinqualityimprovementandhealthsystemredesign:ThreeCanadiancasestudies.HealthcareManagementForum,29(5)176-182.

• Ferrari,M.(2012).ImprovingPatientexperienceintheinpatientSetting:ACaseStudy ofThreeHospitals.AligningforcesforQuality.AligningforcesforQuality.-RobertWood Johnson Foundation.

• InstituteofMedicine(2001).Crossing thequalitychasm:anewhealthsystemforthe21stcentury.Washington,DC:NationalAcademyPress.

• KingBJ,Mills PD,ForeA,MitchellC.(2012).TheDailyPlan®:Includingpatientsforsafety'ssake. NursingManagement,43(3),15-8.

• Maloney, L.R,Weiss, M.E.(2008).Patients’perceptionsofhospital discharge informational content.ClinicalNursingResearch,17(3),200-219.

• NationalCenterforPatientSafety(2009).TheDailyPlan:involving patientinpatientsafety.http://www.patientsafety.va.gov/docs/TIPS/TIPS_JulAug09.pdf

• Nosbusch, J.M.,Weiss, M.E.,Bobay,K.L.(2011).Anintegratedreviewoftheliteratureonchallengesconfrontingtheacutecarestaffnurseindischargeplanning.JournalofClinicalNursing,20(5-6),754-774.

• VANationalCenterforPatientSafety.http://www.patientsafety.va.gov/index.asp

References


• TeamMembers– JeremiahBartsch BSN,RN– ErikaBonds,BSN,RN– ColleenEckert,MPH,RN– KristyFritz,BSN,RN– LauraHale,MSN,RN– LindaMasihMSN,RN

• Acknowledgements– MaryHagle,PhD,RN

• NurseScientist– FlowerLewis,MSN,RN

• InitiatedTDP7CPilot2016– MichellePiwowarczyk,BSN,RN

• LeanCenter– ChrisSaggio,BSN,RN

• NursingInformatics– JamesAppazeller BSN,RN

• ClinicalApplicationsCoordinator

primary, secondary & tertiary care

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