ARTICLE IN BRIEF
The story features a case history of a University of Colorado initiative to improve the time it takes to discharge neurology patients from the hospital.
Recognizing that discharging inpatients earlier in the day would free up beds for patients lingering in the emergency department, neurology residents at the University of Colorado Hospital (UCH) in Denver designed a quality improvement (QI) project to speed the discharge process.
The project, which officially ended this summer, incrementally improved the percentage of patients being discharged before 10 am. Equally important, as they worked their way through three Plan-Do-Study-Act (PDSA) cycles, the residents learned that physicians play an important role in organization-wide quality improvement. [The PDSA cycle evaluates a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).]
“Our residents are now starting to get the idea that quality and process improvement in the hospital, or wherever they are practicing, is important for them, it's important for the entire team that takes care of the patient, and it's important for their patients,” said William J. Jones, MD, the hospital's director of inpatient neurology.
WHY QI IS NEEDED
In recent years, many hospitals across the country have sought to speed patient throughput from the emergency department (ED) to an inpatient bed to discharge. Doing so helps patients start treatment more quickly, improves patient satisfaction, and allows the hospital to serve more patients.
“Our hospital was sort of chronically full, and we were having really significant problems with the ED getting backed up because there were no inpatient beds available,” Dr. Jones said. “The hospital was not uncommonly going on divert — ambulances diverted to other hospitals because UCH had no more capacity — and transfers into the hospital were oftentimes delayed.”
UCH neurology residents are required to design and implement a QI project each year, so some residents began focusing on the patient throughput issue. They thought the traditional work flow — patient rounds throughout the morning and discharges scheduled for late in the day — was inherently inefficient, making it ripe for a QI initiative.
PDSA IN ACTION
A project team — a senior resident, two junior residents, two faculty mentors, a nurse leader, and a stroke program coordinator — collected baseline data that showed 14 percent of neurology discharges were occurring before 10 am.
The team set a goal of increasing that rate to 50 percent while not increasing the length of stay, which might indicate patients are held longer than needed to enable an early discharge the next day; not increasing the 30-day readmission rate, which might indicate patients were discharged too soon; and not decreasing patient satisfaction scores.
Although only a few residents served on the QI team, all were responsible for implementing the “intervention” — a QI term that describes the new approach that is being tested — and working toward the project's goal. The project team provided a tracking form listing some common reasons that a discharge might be delayed past 10 am and asked residents to check the appropriate items or provide other information that would help identify why discharges were delayed.
Unlike clinical trials, in which a protocol is used until the end of a pre-defined study period, quality improvement projects use the PDSA cycle approach to speed improvement.
“Process improvement projects are really iterative,” said Dr. Jones, one of the faculty mentors. “You are looking at your data over and over, you are identifying as you go along what's working and what isn't working, and you adapt.”
While some QI projects seek to identify and perfect a new process or workflow that will achieve a particular goal, the project team knew that would not be possible in this case, said Charles Braun, MD, the chief neurology resident who led the effort. Dr. Braun, who is currently a clinical neurophysiology fellow at the University of Michigan Medical Center, said factors outside a resident's control — such as test results that are not available in the early morning or the extra work associated with a patient's discharge to a long-term care facility — make a 10 am discharge impossible in many cases.
Thus, the goal of this project was to identify a way to make early discharges a priority for residents in situations when they can control the discharge time.
“Early on, it became clear that certain residents were doing very well and others were not,” Dr. Braun said.
In another departure from clinical trials, QI projects are not designed to create new knowledge but rather to achieve specific goals. Thus, researching best practices and borrowing ideas that have worked for others is an important activity.
In this case, the first two interventions did not significantly boost the early-discharge rate. This prompted the project team to use another QI concept: Learn from the success of others.
“They were getting a little frustrated so they went to one of our hospital medicine physicians who has done a lot of quality improvement work and said 'Why isn't this working?'” Dr. Jones said.
He advised team leaders to create a competition among residents. UCH's two neurology teams — the stroke team and general neurology team — compete against one another to see which team has the highest rate of early discharges for the month. The winning team receives recognition, such as an invitation to an attending physician's home for a cookout.
That idea of a competition prompted the QI team to start tracking the discharge-by-10-am rate on a weekly basis and prominently posting the data in the resident lounge.
“That created near-real-time feedback on individual performance,” Dr. Braun said. “What we came to learn is that if you can create daily awareness of performance, you are more likely to be successful.”
By the time the project officially ended this spring, 36.4 percent of neurology discharges were occurring by 10 am, up from 14 percent in the three months before the project started. The median length-of-stay held steady, 30-day readmissions dropped, and patients expressed no dissatisfaction with the discharge process.
Over the course of the project, it became clear that performance was tied to positive reinforcement from attending physicians. When attendings did not make early discharges a priority, performance among residents slipped, Dr. Jones said.
On the other hand, when they offered support, performance improved. Near the end of the project, attendings adjusted the departmental routine so morning rounds are no longer conducted from one room to the next down the hallway.
“We identify patients who are ready for — or potentially ready for — discharge that morning, and we round on them first,” Dr. Jones said.
A mobile workstation allows for discharge orders to be entered during the rounds, rather than after rounds are completed. If necessary, a resident is allowed to step out of rounds for a few minutes to help nursing staff arrange for the patient discharge in the morning.
Although the QI project officially ended this summer, the neurology department's goal of discharging at least 50 percent of patients before 10 am remains in effect, he said. Residents and attendings are continuing to build on the lessons learned during the project.
“No QI project is ever truly finished because improvement is always possible,” Dr. Jones said.
The article is part of a continuing series on quality measure initiatives in neurology. For the Neurology Today collection of articles on quality measures, see http://bit.ly/13E6zv7.
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