Working together to improve inpatient care
Before ThedaCare initiated Collaborative Care at its two urban hospitals, nursing staff sometimes felt they spent more time tracking down supplies and information rather than directly caring for patients. To change that, ThedaCare utilized its lean management tools to completely redesign its hospital patient rooms and how they deliver care to patients. The result is happier patients, improved quality, and overall lower costs.
ThedaCare is a non-profit community health system based in Appleton, Wis., comprised of seven hospitals, four of them critical access, and 35 clinics in northeast Wisconsin. With nearly 6,100 employees, it is one of the largest local employers and dedicated to delivering world-class care for its patients. The health system took the Toyota Production System principles of lean manufacturing and adapted it for healthcare. Since 2002, ThedaCare has embraced lean management principles to improve its quality of care, while containing costs.
Inpatient hospital care is one of the most expensive parts of healthcare. Mid 2003, ThedaCare was one of 10 hospitals selected to participate in the Institute for Healthcare Improvement’s (IHI) “Transforming Care at the Bedside (TCAB)” program. The TCAB initiative paired with lean methodology created the framework for a team of front line staff and patients to take a hard look at the way ThedaCare was providing inpatient care. Through an 18 month series of improvement work that redefined care processes and changed clinician roles, Collaborative Care emerged.
Collaborative Care is an inpatient care model that includes multi-disciplinary team members and the patient coming together to create a comprehensive, individualized care plan. In addition, physical facility and staffing changes were made to support high-quality care at a lower cost per case. Other impacts included a reduced length of stay, improved adherence to clinical best practice standards, increased nurse productivity and enhanced patient, staff and provider satisfaction.
The Challenge: Improving In-Patient Care
Jamie Dunham, ThedaCare’s vice president of operations at Appleton Medical Center, said many hospital patients typically feel their care isn’t coordinated and that physicians, nurses, therapists, pharmacists and other healthcare professionals aren’t working together in a coordinated fashion.
“A patient will ask a question and there would be a lot of ‘I don’t knows’ or answers from different people that didn’t mesh,” she said. “Or patients and their families would feel like they kept answering the same questions over and over again, wondering if anyone was talking to each other.”
Hearing our patient perspectives grounded the improvement teams to create processes that brought together clinical team members from different disciplines, including providers, nursing, pharmacy and care management and have them create one, individualized plan of care for each patient collectively. Adding a standard daily care plan review/adjust process by the team, with the patient, would help to improve communication processes among medical professionals that would lead to better, coordinated care for patients.
“When everyone is on the same page, the quality of care improves and patients are able to go home more quickly,” Dunham said. “Shorter hospital stays not only lead to lower costs but also happier patients.”
An additional need was the complete remodel of the physical environment, as it became clear that the current hospital room design and outdated concept of a central nursing station were not conducive to the new delivery model processes being created.
The Solution: Increased communication, redesigned patient rooms
In Collaborative Care, communication among medical professionals plays a central role as a patient’s nurse, provider, pharmacist and care manager develop a plan of care together with patients and their family members. Given the busy schedules of some physicians, many have been able to coordinate their schedules by using mid-level providers to help maintain the spirit of collaboration among the healthcare providers.
“An output to these process changes is discussion about where a patient should be in the healing process. To monitor the healing progression, ‘tollgates’ were created which are set points to analyze a patient’s status and remove any obstacles that are getting in the way of the healing process,” she said.
The new process also put a spotlight on right clinical role doing the right work at their highest scope of practice. For example with Collaborative Care, a medication reconciliation specialist (pharmacy extender), rather than a nurse, became responsible for checking with patients and their family members that the list of medications being taken at home is complete and accurate when they enter the hospital. This provides an important baseline for how medications may be prescribed during the patient’s hospital stay and their next level of care. This change reduced the medication errors per patient admission to nearly 0 from about 1.5.
Collaborative Care also physically changed the layout of hospital patient rooms and departments. Rooms were redesigned to put more supplies, medication, and electronic record-keeping systems for real time documentation near the patient’s bedside so nursing staff could spend more time taking care of a patient rather than hunting and gathering supplies or going back to a central nursing station to look up a patient’s file. These changes improved efficiencies by reducing unnecessary steps and interruptions enabling nurses to increase the time they spend with patients by 70 percent. Being able to spend more time with patients’ means higher quality of care is delivered, Dunham said.
“The new rooms were designed with patient safety in mind – a lot of little changes add up to make a big difference,” said Shana Herzfeldt, director of operations for ThedaCare’s Collaborative Care model.
For example, Herzfeldt said each room contains a ceiling lift, outlets at waist level height, beds with alarm and weighing capabilities, commodes, walkers, gait belts as well as hand rails throughout the room to promote patient and staff safety. Also, a white board that illustrates staff members’ names, patient’s plan of care, goals, important notes or reminders (such as “Always ring for the nurse before getting out of bed”), and the estimated discharge date to keep the patients and families informed of the plan.
The Results: Happier patients, better cost control
Collaborative Care involves patients from the point of admission. The goal is to include the patient and family in creating an individualized plan of care that safely transitions them to the next level of care with the necessary resources. “That’s what patients always want to know, ‘when can I go home?’ so we provide a discharge goal upon admission, focus on interventions needed to progress care and work to remove any barriers that interfere with that plan to meet the goal,” Dunham said.
Focusing on setting discharge dates along with patient progression using the tollgates leads to shorter hospital stays and lower costs. Since Collaborative Care was implemented, the average cost per medical case decreased by 8 percent while the average cost per surgical case decreased by 12 percent.
“Communication with patients and their families about the discharge goal and what is being done to meet it is crucial,” Dunham said. This sharing of information has led to patients being more satisfied with the level of care they’ve received.
Dunham said Collaborative Care isn’t just about new process flows, it’s a cultural change, paradigm shifts, that include professionals working together in different roles supported by a lean created environment to achieve better outcomes. Overall, ThedaCare has proved that a patient-centric environment can improve quality and lower the cost of care.
“We continue to make tweaks and constantly look at ways to improve and adapt,” she said. “We have a philosophy of continual improvement and it’s something we take seriously.”