Discharge coordination of care process improvements

DISCHARGE COORDINATION OF CARE PROCESS IMPROVEMENT

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Group50 Consulting All Rights Reserved 2017 (909) 949-9083 Slide 2

Value Stream: In-Patient Flow – Discharge Coordination of Care
Business Case
Primary: Quality Outcomes, Readmissions
Secondary: Cost, Patient satisfaction, LOS
Problem Statement:
The current processes and systems to communicate and coordinate patient
flow from ‘decision to discharge” to patient arrival at destination with all
support in place (DME, home health agencies, SNF.. etc) results in less than
ideal communication, coordination, patient satisfaction, family satisfaction
and employee frustration
Desired State:
Design, Document, Implement and Deploy a process to reduce the time from
“Butt in Bed” to “patient departure from unit with all support in place” by 25%.
Complete support will always be in step with the scheduled discharge plans.
Charter

Charter: Objectives
• Establish common understanding of the current state
• Identify key individuals impacting the process
• Med Rec
• Improve communication with patient & family to understand &
come to agreement with the transition plan
• Define timeline for nursing to address ‘discharge written’
patients
• Case management staff notified of “d/c written” within in 30
minutes
• Social Work staff coordinates referral to appropriate
community agencies and confirm receipt of information
• Social Work staff identifies DME/other needs for discharge
• Physician will identify anticipated d/c one day in advance
• Patients/Family will be notified of anticipated d/c date based
on physician input

Charter: Objectives
• Understand opportunities for improvement as identified by:
• SNF’s
• DME supplies
• Home Health Agencies
• Physicians
• Ancillary Services
• Nursing
• Case Management
• Care Navigators
• Hospice
• Palliative Care
• Social Work
• Private Educators
• Identify process and parameters for revenue/cost risk resolution

Our Process
Issues &
Opportunities
Admission Day
On-Going Care

Our Process
Pre-Discharge Day
Discharge Day
Post Discharge
Issues &
Opportunities

Understanding our Process: Wastes
Admission Day
BIB
Ongoing Care Day of
Discharge
Post Discharge
Care
Pre-Discharge
Day
• Inconsistent
Admission
process in first
2 hrs of
admission
• Discharge
Education
starting at
Admission
• Consistent
reinforcement
from Hospitality
• Understanding
roles,
responsibilities
and timing of
care utilization
team
• Limited and
inconsistent
preparation
work for
patient
discharge
• Medication
Rec is
inaccurate for
the post
discharge
settings
• No Rx
• Lack of
medication
education to
patient
• Disruptions
and delays
in the
discharge
process

Changes and Improvements
• Rounding board pilot on 5th floor for Doctors to communicate
approximate round times for following day.
• Initiate nurse/provider rounding sheet.
• Patient Flow board
• Improved admission packet.
• “Plant the seed” of discharge on admission day to better prepare
patient.
• Noted that Pharmacy could be used in education process with
medications to free up Doctor / Nurse time.
• DME supplies identified earlier to allow time to fill “script”.
• Triangle (Social Work, UR, Case Management) better defined and
areas where they can assist.

• Possible problems with filling scripts captured to prevent
readmission due to meds.
• Idea of “Time Buckets” discussed to allow for better planning on
discharge – used in conjunction with Rounding board.
• Consulting physicians now “sign off” earlier to prevent
numerous phone calls at time of discharge to get approval.
• Non-brand specific Liaison for HHH and Birchaven to capture
more business and assist in lowering readmission rates due to
after care.

• Arrange transportation on day before discharge to save time on day of
discharge.
• Moved more discharge processes to day before discharge to be more proactive
instead of reactive.
• Implement new belongings sheet to assist in preventing loss.
• Making follow up appointments for patients to assist with core measures.
• Located key points where HA can assist nursing with processes to free up more
time for nursing staff.
• Noted key areas for improvement for SNF, Palliative Care, Assisted Living, etc.
• Create and implement discharge planning sheet.

Patient Transportation
arrangements
Benefits:
•Allows for coordination
of the care team pre-
discharge
•Creates a smooth
discharge process to the
patient’s post discharge
care
Consulting physicians sign off for
patient discharge pre-discharge day
Discharge Day
and Post
Discharge
Patient Needs

Patient Flow Board
Projecting the expected
patient discharge day
according to DRG &
Insurance Information
The patient discharge checklist is to
ensure all required discharge needs
are executed before the patient is
discharged
Benefits
• Visual communication
of the patient discharge
flow that is coordinated
with post discharge care
• Communication of a
patient’s LOS that will be
paid for by Medicare and
all other insurance
companies based on
current provider
documentation
• Coordination of patient
flow to ensure safe and
efficient patient discharge

Physician Rounding Board
Provider Name
and Rounding
Times
Benefits
•Allows RN to coordinate
care for a 12 hour shift
•Facilitates quality care from
Admission to Post Discharge
Care
•Predicts rounding time of
Physicians
•Smoother flow through
patient discharge

Performance Metrics
Metric Baseline AFTER
• 72%ile
• 85%ile
• 170 min
• 42%
47%
• 10%
• 33%
• 4%
% CHANGE
Service Excellence
• Communication about Meds
• Patient Discharge Info
Quality
• Time to Discharge Patient
• Patients Discharged Prior to
2:00pm
Post Discharge Care (Medicare)
• Home Health
• SNF
• Hospice
• 90%ile
• 92%ile
• 90 min
• 80%
64%
• 18%
• 40%
• 6%
• 25%
• 8.2%
• 50%
• 90%
36%
• 80%
• 21%
• 50%

Leading Indicators
• Number of observation patient over 23 hrs.
• Patients admitted to wrong status
• UR Chart review of all patients within 24 hrs. of admission
• # of potential referral/# of total admissions
• # of actual referrals/# of total admissions
• Physician pre-discharge rounding sheet is completed
• patient discharged within 2 hrs. of attending physician
discharge order
• All paperwork is physician ready before discharge rounding

Leading Indicators
• All core measures are completed before patient discharge
• # of calls to the physician on discharge day after discharge
rounding
• # of yellow and red boxes on patient flow board with no
discharge written
• # of red boxes on patient flow board with no discharge
information
• Admission medication list is done with 60 mins.
• Referral information is all complete and no contact back to
hospital

Standard Work
• Patient BIB
• Ongoing Care
• Pre-Discharge
Day
• Discharge – Post
Discharge Care
• Social Work
• Case
Management
• UR

Lessons Learned
• Better way to discharge (whole process)
• So excited about it!
• Sometimes I should just shut up!
• Gina is really very shy!
• We are all one team
• Home Health & Hospice, Pallative Care, etc, needs vital
info from beginning for continued care / smooth
transition.
• Flow Board has more info than most staff know about.
• Our current process is not effective and will take a lot of
work to improve.

Lessons Learned
• Fixing problems in the system is a team effort that is
going to take everyone’s cooperation to be successful.
• Gina is teacher’s pet.
• Creating a team to solve a problem can bring great ideas
and plans together.
• Doctor’s don’t love frequent phone calls as we previously
thought.
• Learned about the Social Work / Case Mgr / UR triangle
• Learned what Home Health does vs. Palliative Care
• Vinnie reads lips
• The flow of patient care.
• Our processes are a mess and we lose a lot of $ every
day due to processes

Lessons Learned
• We have a lot more work to do……
• Vinnie shaves his head – not really bald!!
• That we don’t have to be silos – we work well as a team.
• Collaboration between Physician / RN can’t be left to
chance – we need to commit to it!
• Critical that discharge starts at the day of admission.
• Criticality of RN / Physician rounding in coordination of
Patient Care / Service Excellence.
• Red is no $$ - Patient Flow Board
• Empowering our unlicensed staff will help facilitate
quality care

Parking Lot - Completed
• Patient life style outside of BVHS?
• Physician prediction of discharge – different on each floor
• When do we have to notify the consulting physicians for
discharge
• During the patient care what technique can be use so we
know if the consultation want to be contact at the patient
discharge.
• is it a hippa violation to share patient information before
they agree to post discharge services
• physician (fox) wants to have everything ready to go day
before discharge
• Hospitality is viewed differently on different floors
• Pre- discharge checklist, foley cath, IV ATB etc….
• <50% of patient records have ”Plan to discharge
tomorrow”
• Day of admission set the expectation for discharge time
• ambulette coordination at discharge
• Best Practice of all medication education, new or old meds
• “Routine” vs. CHF,PN taking meds – detail of medication
list – pharmacy teaching
• screen people in as candidates vs screen out
• adding discharge protocol to hospitality and going over
admission packet by hospitality
• Add to nurses order “pharmacy consult”

Parking Lot - Open
• What can we anticipate based on patient diagnosis?
• Pre-authorizations from insurance companies?
• hard to find the time of death for the physicians (death and dying arrangement screen)
• Code 44 for next PI Event, decision to admit
• Medication administration time
• who is the nurse to discharge the patient and think about who is admitting them, who
knows their case the best
• charge capture process on the floor
• ED discharge to SNF – specifically Med Rec
• Computers that don’t work on the floors
• directing medication prescription to outpatient pharmacy
• Nurse to Patient Ratio
• staffing model balance
• Bridge palliative care how do we explain non branded information on HH
• What is the relationship between interdisciplanary rounds and coding?
• Observation unit or rooms dedicated to observation patients
• Computers on the nursing floors do not function properly

Group50 Contact Information
Website: www.group50.com
email: Info@Group50.com
LinkedIn: https://www.linkedin.com/company/2098102/
Phone: 909-949-9083
VINCENT “VINNIE” POLITO is Group50’s Healthcare Practice leader has over thirty years of experience
as an executive and executive consultant in the design and delivery of Lean, Lean Transformation and
operational Excellence in the Healthcare, Medical Device, Industrial Manufacturing, Aerospace,
Textile and Oil and Gas industries. He has held senior management roles in operations, materials,
quality, and business det.
Vinnie has pioneered Lean in Healthcare. At the forefront of Lean in Healthcare since 2003 he has provided guidance to
over 100 hospitals, physician/specialty practices, insurance health plans and home health systems in North America. He
has a grasp and appreciates of the mission and complexity of Healthcare. He translates Lean principles and techniques
into effective delivery strategies and execution specifically meeting the critical needs and culture of Healthcare. Some his
more notable Healthcare clients include, Thedacare, Denver Health, Beth Israel Deaconess, Barnes Jewish, New York
Health and Hospitals, and Priority Health. His Lean support of Healthcare has included initiatives for non-clinical
organizations including the Institute of Medicine (IOM), the Institute for Healthcare Improvement (IHI) and National
Quality Forum (NQF).
Vinnie has led and executed Lean transformation in a diverse range of industries such with a client list of Fortune 500
organizations including Boeing, Alcoa, Lockheed Martin, Rockwell-Collins, Duracell, Owens-Corning, Sandia Labs and
Hanes Brands.

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