Length of Stay Collaborative at BC Women s Hospital

1. Length of Stay Collaborativeat BC Women’s Hospital Georgene Miller Corporate Director Medical Affairs, Quality, Safety & Risk Management Provincial Health Services Authority (604) 875-2679 gmiller@cw.bc.ca

2. Building on Success BCW Best Practices Initiative in 2003 Length of stay (LOS) for postpartum women higher than experienced by other similar agencies Longer LOS associated with increased risk of infection, adverse events Impact on access due to high demand for beds (over 7,000 births per year) BCW Best Practices Initiative in 2003 Baby-friendly initiative, changes to surgical practices to improve quality Found length of stay (LOS) for postpartum women was higher than experienced by other similar agencies Longer LOS associated with increased risk of infection, adverse events Impact on access due to high demand for beds (over 7,000 births per year) BCW Best Practices Initiative in 2003 Baby-friendly initiative, changes to surgical practices to improve quality Found length of stay (LOS) for postpartum women was higher than experienced by other similar agencies Longer LOS associated with increased risk of infection, adverse events Impact on access due to high demand for beds (over 7,000 births per year)

3. Advancing Quality & Safety Internal Collaborative Institute for Healthcare Improvement (IHI) Collaborative model Joint effort among multiple individuals and/or groups that share resources and information Achieves goals that would not have been attainable for individuals or groups working alone (both scope and pace)

5. Collaborative Model Joint leadership from Department of Quality, Safety & Risk Management (process) and BCW (content) Four multidisciplinary teams Multiple small tests of change conducted over short time and measured for impact

6. Strategies Weekly team leader and coach meetings Regular team meetings on units Group learning sessions ExtraNet Newsletters and brochures Poster session luncheons Quizzes and prize draws

7. Strategies Weekly team leader and coach meetings Regular team meetings on units Group learning sessions ExtraNet Newsletters and brochures Poster session luncheons Quizzes and prize draws

9. Goals Maintain or improve quality of care and patient safety AND Maintain or improve patient and staff satisfaction AND Increase accessibility WHILE Decreasing LOS for women following uncomplicated deliveries

10. Measurement Chart audits Surveys (staff and patients) Time studies Ongoing monitoring LOS Readmissions/hospital visits Feedback from community

11. Measurement Chart audits Surveys (staff and patients) Time studies Ongoing monitoring LOS Readmissions/hospital visits Feedback from community

12. Postpartum Discharge Class: Mother’s Questionnaire Date: February 3, February 8, 2005 We want to know if the Postpartum Discharge Class was helpful. Please take a few minutes before leaving the class to answer the following questions. What information was new to you? Normal Breastfeeding pattern Yes ? No ? Baby voiding & stooling pattern Yes ? No ? When to call for help Yes ? No ? Mother Yes ? No ? Baby Yes ? No ? Basic baby care Yes ? No ? Other help Yes ? No ? Comments: ____________________________________________________________________________________________________________________________________________________________________________ What did you find most helpful? ____________________________________________________________________________________________________________________________________________________________________________ What did you find least helpful? ____________________________________________________________________________________________________________________________________________________________________________ Did the class help you to be better prepared to go home? Yes ? No ? Overall, how helpful was the class? Not helpful somewhat helpful Very helpful 1 2 3 4 5 Other comments/suggestions: ____________________________________________________________________________________________________________________________________________________________________________

13. Changes 1. Improve efficiency 2. Standardize processes and reduce variation 3. Communicate and educate 4. Strengthen community partnerships

14. 1. Improve Efficiency Mapped patient flow and identify delays Replaced taped nursing handover report with written report Established discharge teaching classes Ensured timely newborn screening can be done in community for babies discharged <24 hours of age Began planned discharge time practice

15. 1. Improve Efficiency Mapped patient flow and identify delays Replaced taped nursing handover report with written report Established discharge teaching classes Ensured timely newborn screening can be done in community for babies discharged <24 hours of age Began planned discharge time practice

16. Replaced Taped Report with Written Report Hunch: Changing nursing handover format will give nurses more time to spend with patients, increase time available to admit/discharge PDSA: Measure time spent on taped report, seek input from nurses, identify alternatives, develop tools, pilot new system, seek feedback, roll out to all units, measure time spent on written report Outcome: Time reduced by nearly 50% from ˜ 1 hour to ˜ 30 minutes twice per day When patient flow was mapped, noted that there were delays in admitting and discharging patients of up to two hours twice a day between 0600 and 0800 and 1800 and 2400 as nurses were busy preparing to tape report, taping report, and listening to taped report and were unavailable to patients.When patient flow was mapped, noted that there were delays in admitting and discharging patients of up to two hours twice a day between 0600 and 0800 and 1800 and 2400 as nurses were busy preparing to tape report, taping report, and listening to taped report and were unavailable to patients.

17. Nursing Handover Report Times Time for Yellow Unit Tape & Listen is estimate only – no accurate pre-measurement was done as tape recorder broke and they went directly to written report. Best results are seen by Yellow Unit, who have been using written report the longest. Time saved by Red Unit is less; they were the third unit to make the change and were very reluctant – they worked hard during the pre-measurement period to keep their time spent on taped report as short as possible in the hope they wouldn’t have to make the change, and are still getting used to the written format. Time for Yellow Unit Tape & Listen is estimate only – no accurate pre-measurement was done as tape recorder broke and they went directly to written report. Best results are seen by Yellow Unit, who have been using written report the longest. Time saved by Red Unit is less; they were the third unit to make the change and were very reluctant – they worked hard during the pre-measurement period to keep their time spent on taped report as short as possible in the hope they wouldn’t have to make the change, and are still getting used to the written format.

18. 2. Standardize Processes & Reduce Variation Implemented criteria-based discharge Revised Pathways tools Incorporated teaching checklist Created community follow-up form

19. 2. Standardize Processes & Reduce Variation Implemented criteria-based discharge Revised Pathways tools Incorporated teaching checklist Created community follow-up form

20. Implemented Criteria-Based Discharge Hunch: Standardizing criteria for discharge readiness will reduce variation in LOS related to staff experience, values, opinions PDSA: Audit practices, identify guidelines for discharge readiness, create and trial tool, seek input and feedback, roll out, audit new practices Outcome: New multidisciplinary tool integrated with Pathways documents, supports SBAR communication and shared mental model about discharge readiness

21. 3. Communicate & Educate Implemented SBAR Developed EduQuick Created and distributed brochure Held manned poster session in BCW hallway Ensured alignment of information in prenatal classes with LOS goals

22. 4. Strengthen Community Partnerships Identified variations in support available geographically Created reciprocal resource binders Worked collaboratively on newborn screening test changes Established lines of communication to facilitate joint problem-solving

23. Lessons Learned Leverage other initiatives to achieve maximum gains (e.g. accreditation) Inform unions of projects early on to prevent misunderstanding Provide backfill to allow nurses to fully participate Move ahead even if all participants are not fully engaged

24. Lessons Learned #2 Change using PDSA model requires major paradigm shift, especially for researchers Challenge to engage physicians who are “contractors”, not “staff” Success relies on strong, consistent, informed Collaborative leadership AND willingness of staff to try new things Impossible to over-communicate!

25. Leading to Excellence Staff learned new problem-solving skills using PDSA Stronger interdisciplinary relationships developed through Collaborative work carry over into clinical practice Participants developed a greater awareness of their roles in promoting patient safety and quality

26. Leading to Excellence #2 Staff have better understanding of continuum of care with community Stage is set for use of the Collaborative model to address other quality and safety issues

27. For more information: Judy Komori Collaborative Improvement Advisor (604) 875-2105 jkomori@cw.bc.ca Kim Steger Collaborative Coordinator (604) 875-2345 x 5325 ksteger@cw.bc.ca Annemarie Taylor Collaborative Director (604) 875-3007 ataylor@cw.bc.ca