VETERANS HEALTHADMINISTRATION Sl ide 1
Clement J. Zablocki VA Medical Center
Primary,Secondary&Tertiarycare
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Relationship Based Care Nursing Practice Model
• Threeuniquerelationshipsexist
• Eachisimportantandnecessary–NursetoVeteran–NursetoNurse/Others–NursetoSelf
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Pilot Site – 7C
30bedmedicalsurgicalacutecareAveragelengthofstayis2.8days
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Target State Process Map
Patientadmittedto7C
Patientreceivescare
Dailyinterdisciplinarycommunicationwithpatientregardingcareanddischarge
Providerwritesdischargeorders
Orderscompletedbyvariousstaff
Patientdischargedfrom
7c
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How Did it Feel for Veterans and Team?
§ Rushed§ Unplanned§ Chaotic
0102030405060708090
100
BaselineOct-Dec2015
Extentfeltreadyfordischarge
Speedofdischargeprocess
Thenurse keepingthepatient informed
Thephysciankeepingthepatient informed
Instructions forcareathome
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What Were We Striving For?
§ Planned§ Organized§ Mutualagreement
0
10
20
30
40
50
60
70
80
90
100
Extentfeltreadyfordischarge
Speedofdischargeprocess
Thenursekeepingthepatientinformed
Thephyscian
keepingthepatientinformed
Instructionsforcareathome
BaselineOct-Dec2015
Extentfeltreadyfordischarge
Speedofdischargeprocess
Thenurse keepingthepatientinformed
Thephysciankeepingthepatient informed
Instructions forcareathome
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Gap Analysis
Barriers Cause
CommunicationMinimal interdisciplinarycommunication/coordination inadvanceofdischargeday.
Complexity Lack ofdischargeplan resultsinpotentially delayeddischargerelatedtotransportation, homecaresuppliesandequipment.
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Solution Approach
Ifwedothesethings…then wewillimproveVeteranSatisfaction…..
Allclinicians updateInterdisciplinaryDischargeCarePlan inElectronicMedicalRecord(CPRS).
CommunicateregularlywiththeVeteran aboutprogresstowardDischargeandtheDischargePlan
Proactivelyaddresscomplexdischarges*priortothedayofdischargetoensureallneedsaremetandthepatientknowsthefullplan.*Dischargesrequiring homecare,transport,supplies/equipment, Veteran/caregivereducation
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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
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Why Use The Daily Plan ® ?
• EncouragesVeteranand/ortheirfamilytospeakupandbeinvolvedintheircare
• Providesanopportunityforpatienteducation• Establishesaplantohelpguide/progressthecare• Facilitatesandaugmentsthedischargeplanningprocess
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Things we tried and then changed…... (PDSA)
• VeteranOrientationtoTheDailyPlan®
• PreparationofTheDailyPlan®envelopes
• SurveyingPatientandstaffRN’sabouttheirsatisfactionwithTheDailyPlan®
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Our Daily Plan Innovation• ModifiedtheNationalDailyPlantoinclude
– InterdisciplinaryDischargePlan(IDDCP)Notes– PertinentLabValues
• OurProcess– NursereviewsTheDailyPlanwiththeVeteraneverymorning
– Veteransareencouragedtoaskquestions
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------------------ 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
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Confirmed State Process Map
Patientadmittedto7C
TheDailyPlan(TDP)printedanddiscussedonadmission
MSAprintsTDPeachmorningat10:00AM
NursereviewsTDPwith
patienteverymorning
Patientconfirms
understandingofTDP
Patientdischargedfrom7c
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Lessons Learned
•Communicationisessential– Interdisciplinaryteam–VeteranInput
•WhatfactorsintotheVeteranbeingreadyfordischarge?
•Whatfactorsimpactatimelydischarge?
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Next Steps
• ContinuedcollaborationwithITtomakeTheDailyPlan®asuserfriendlyaspossible.
• Ongoingoutreachandeducationforclinicians(PT/OT,SW,MedicalandSurgicalResidents,hospitalists,NP’s,supportstaff,andfloats
• Takingthisinitiativehouse-wide!
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• 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
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• 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