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RAPID: Revamping the admission process to inpatient departments

Shoalhaven District Memorial Hospital
Project Added:
26 August 2019
Last updated:
29 August 2019

RAPID: Revamping the admission process to inpatient departments

Summary

RAPID is a collection of projects that were developed by staff at Shoalhaven District Memorial Hospital (SDMH) (n=103) to address a range of issues. These issues contributed to a delayed medical patient journey across three areas:

  1. Limited bed access
  2. Aged care assessment team (ACAT) referral process
  3. Fragmented interdisciplinary communication.

View a poster from the Centre for Healthcare Redesign graduation, August 2019.

RAPID poster

Aim

To improve the journey of medical patients admitted through SDMH’s emergency department (ED).

Benefits

Patient benefits

  • Timely contact with the patient’s contact person, such as next of kin or other caregivers.
  • Reduction in the length of time patients spend in hospital.
  • Improved safety and consistent communication with patients about the plan for their care and discharge.

Staff benefits

  • Reduce wasted time spent when trying to confirm and contact the patient’s contact person.
  • Improve interdisciplinary communication and staff relationships.

Healthcare system benefits

  • Financial savings through streamlined processes.
  • Improved hospital admission and patient discharge processes.
  • Reduction in the amount of time sourcing accurate patient contact person despite inaccuracies in electronic records.

Background

We all want 100% of our time to matter but patients can spend an average of 11.6 hours, over 7 hours longer than they should, waiting in the ED for an inpatient bed. This comes at a cost of more than $ 2.8 million every year.

Patients of SDMH say this long delay makes them feel uncomfortable, not heard and restricted.

To address this, lots of improvement work is being done in the ED for admitted patients who have no beds in the hospital for them to move into, given that efforts so far have been unsuccessful in reducing the time patients are left waiting.

The RAPID project focuses on addressing delays towards the end of the patient’s journey to free up acute medical beds earlier for patients waiting in the ED.

Implementation

Solution 1: Accurate family/carer contact details in the electronic medical records (eMR) software

By improving the accuracy of a patient’s person to contact in eMR, such as next of kin and other caregivers, patients who require complex discharge plans will have their families contacted earlier. This means processes that support discharge decisions can happen sooner. One example is requests for an ACAT assessment, which currently takes five days to be sent after our patients are no longer acutely unwell.

Steps

  • Local Administrative Manager will continue to be the site project owner.
  • Escalation of the issue within iPM (patient manager) software and eMR has been handed over to the Illawarra Shoalhaven Local Health District and South Eastern Sydney Area Health Service eMR/ iPM managers as this was identified as a district/statewide issue.
  • Locally administrative staff have had a change in their level of access to allow them to make changes to family/carer contact details in iPM so that the correct information is displayed accurately in eMR.
  • Quick reference guides have been developed and disseminated locally.
  • iPM and eMR have fixed the issues with family/carer contact details being transferred accurately, ready to go live on August 2 2019.
  • District performance team will provide re-training for all administrative staff across the local health district, starting with SDMH once changes are made after the August go live date.
  • ISLHD standard 6 & 8 committee will develop a procedure for the process of accurately recording family/carer contact details in iPM and eMR.

Status

Pre-implementation

Solution 2: Case management of patients requiring complex discharge planning

To implement a standardised and co-ordinated process for managing patients with complex discharge planning needs, such as patients who require new residential aged care facility placement or increased services upon discharge. This is still being developed.

Steps

  • Five solution design workshops to run, which use Clinical Health Redesign methods to brainstorm solutions based on issues presented.
  • Review and research into other health districts for similar project rollouts.
  • Design of terms of reference and meeting agenda.
  • Benchmarking with other hospitals is currently underway.

Status

Planning – Planning for the project is well underway. Clinician and consumer consultation has occurred, however solutions have not yet been developed.

Solution 3: Plan on top

Allied health (physiotherapy, occupational therapy, speech pathology, dietetics) have improved the readability of patient’s plans and recommendations for discharge in eMR.

This is to support improved interdisciplinary communication.  Patients’ plans and recommendations are now at the top of the progress notes in a standardised layout.

This will improve the frequency of nurses and doctors reading allied health notes. In turn, this reduces human error and improves patient safety and timely and efficient care planning.

Steps

  • Run a solution focus group with allied health staff across disciplines.
  • Review and research marketing and online web typography studies.
  • Engage solution owners from specific disciplines.
  • Obtain baseline results from documentation audit.
  • Develop pilot templates specific to each discipline.
  • Modify individual notes by each allied health professional involved.
  • Run monthly documentation audits.
  • Obtain monthly feedback from documentation audits.
  • Hold various presentations at multiple district and local meetings, to publicise the project.

Status

Sustained – The project has been implemented and is sustained in standard business.

Solution 4: Who’s who in the zoo? Allied health badges (Quick win)

Create improved identification of staff caring for the patient while in hospital, to support improved interdisciplinary communication. Allied health staff are now more easily identifiable by wearing badges with their discipline featured.

Steps

  • Solution created by solution sponsor.
  • Email of suggested solution to allied health unit heads to obtain buy in.
  • Development of first pattern of badges and distribution.
  • Feedback from non-allied health stakeholders post-four week trial
  • Modification of badges as per feedback.
  • Development and distribution of second pattern.
  • Various presentations at multiple district/local meetings to publicise the project.

Status

Sustained – The project has been implemented and is sustained in standard business.

Solution 5: Discharge medications

Discharge medication scripts are available with the doctors during their rounds. The discharge scripts are immediately signed on the medical round when the patient is deemed ‘discharge ready’. Discharge script previously took two hours to get to pharmacy to be dispensed.

The solution is to have a central location on the ward and a process whereby the ward clerk or designated nurse will be notified and will send the script to pharmacy as soon as it is completed.

This solution aims to reduce the time it takes for discharge medications to be completed so that patients may be discharged earlier in the day, freeing up acute beds.

Steps

  • Meetings arranged with solution sponsors/ owners/ target representatives.
  • Solution halted due to roll out of district wide project – ‘eMEDS’.

Status

Future initiative – The project is in the operational plan or is an active work project.

Solution 6: Who’s who in the zoo? Nurse photo boards

Nurses caring for each patient have their photos and names above patients’ beds, outside patients’ rooms and in the nurses station, so that they are more easily identifiable.

Steps

  • Meetings arranged with solution sponsors/ owners/ target representatives.
  • Creation of a large board on each ward with photos and first names of the nursing staff on shift and which patient/s they are caring for.
  • Photos displayed outside each patient room changed at handover.
  • Photos above patients beds are changed when staff change their shifts

Status

Implementation

Dates

July 2018 – August 2019

Implementation site

Shoalhaven District Memorial Hospital

Partnerships

Results

Solution 1: Correct patient and carer contact details

This solution has been handed over to:

  • the Local Administrative Manager for further audit and evaluation
  • the district performance team for re-training of all administrative staff district wide
  • the district eMR support team for quick reference guide development and dissemination.

Pre implementation audit showed 16% of errors in NOK contact details between iPM and eMR.

Solution 2: Complex Case Management Team

The solution to improve the planning for our chronic and complex patients is still in planning. The implementation for the pilot is scheduled for October 2019.

The project design will continue with the general manager. Benchmarks are currently being piloted against another site and an implementation plan will be provided for a new model of care to manage long-stay patients.

Solution 3: Plan on top

This solution has been implemented and undergoes a monthly evaluation.

Results include the following.

  • Three months after implementation there has been an improvement in how often there is evidence in nurses’ and doctors’ eMR notes that they have read the plans and recommendations were made by allied health professionals.
  • This improvement is from 41% to 70%. The solution is now in a part of standard business operations in the SDMH allied health orientation.
  • For further sustainability, the solution is being rolled out to other hospitals across the district.

Solution 4: Who’s who in the zoo? Allied health badges

This quick win solution has been implemented and evaluated, to show that 82% of staff provided positive feedback for the badges. The badges were then modified according to feedback. The solution is now in a part of standard business operations in the SDMH allied health orientation. For further sustainability, the solution is being rolled out to other hospitals across the district.

Solution 5: Discharge medications

The introduction of eMEDs has meant that a solution has not been able to be implemented. The project has been handed over to the director of pharmacy and the director of nursing & midwifery services to implement the solution.

Solution 6: Who’s who in the zoo? Nurse photo boards

This solution went live on 30 July 2019, starting with one medical ward then to be rolled out across all medical wards. The solution will be implemented as a staged approach. Firstly with a central photo board in the nurses’ station. Then photos will be placed above every patient bed, and lastly, placed outside patients’ rooms.

Lessons learnt

  • The success or velocity of implementing solutions into practice is directly proportional to how close the solution owners/ champions are to the solution targets, and source of the problem.
    • Example 1: Plan on top and allied health badges – Wearing the allied health uniform when implementing solutions with the allied health target group demonstrates that the solution owners and champions are not outsiders, rather ‘one of them’. This helps to create efficiency in the work place.
    • Example 2: Nurse photo boards – Having the first photo displays showcased by the solution owners/ champions, rather than an ‘outsider’, helps to minimise resistance and promote a sense of comfort, trust and leadership.
  • Sometimes the people you think are the most suitable champions may not be the most suitable champion throughout redesign journey.
  • It takes much longer than 12 months to design, implement and sustain solutions, with difficulties mainly due to other staff needing time to complete processes within each project solution.

Further reading

  • The Advisory Board
  • #Hello My Name Is… Campaign
  • Bates DW, 2015. Health Information Technology and Care Coordination:The Next Big Opportunity for Informatics?. IMIA Yearbook of Medical Informatics, Volume 10, pp. 11-14.
  • Davidson A. 2011. Translational Research. What Does it Mean?. Anaesthesiology, Volume 115, pp. 909 - 911.
  • Fessenden T, 2018. NNGroup Scrolling and Attention. [Online] Available at: https://www.nngroup.com/articles/scrolling-and-attention/
    [Accessed November 2018].
  • Hines P. 2010. The Principles of the Lean Business System, Cardiff: S A Partners.
  • Maria JS. 2014. How We Read. [Online] Available at: https://alistapart.com/article/how-we-read [Accessed November 2018].
  • National Institutes of Clinical Studies. 2006. Taking action locally: eight steps to putting cancer guidelines into practice, Melbourne: National Institutes of Clinical Studies.
  • Shimp K. Sims A. 2016. Photo Identification on a Medical-Surgical Unit Improves Communication Resulting in Positive Patient Outcomes. Nursing Economic$, 34(6), pp. 309 - 311.
  • White S, et al. 2016. Can gossip change nutrition behaviour? Results of a mass media and community-based intervention trial in East Java, Indonesia. Tropical Medicine and Internation Health, 21(3), pp. 348-364.
  • Zamzuri A, et al. 2013. Reading on the computer screen: Does fon type has effects on web text readability?. International Education Studies, 9 January, 6(3), pp. 26-35.

Contacts

Jenny Lay
Physiotherapy Primary Care Practitioner
Wollongong Hospital
Senior Emergency Department and Geriatrics Physiotherapist
Shoalhaven District Memorial Hospital
Illawarra Shoalhaven Local Health District
Phone: 02 4423 9272
jenny.lay@health.nsw.gov.au

Natalie Wright
Whole of Health Project Manager
Shoalhaven District Memorial Hospital
Illawarra Shoalhaven Local Health District
Phone: 0439 36 3713
Natalie.Wright1@health.nsw.gov.au

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