Redesign promotes patient-centered care
New role includes elements of CM, charge nurses
With the dual goals of increasing operational efficiency and promoting patient-centered care, Northwest Community Hospital in suburban Chicago revamped its care delivery model, adding a new role of clinical care coordinator to facilitate smooth and timely transitions from admission to discharge.
"We were looking for an opportunity to transform the hospital’s culture to be both performance-oriented and patient-centered. We wanted to give people tools for real-time performance improvement but to focus on patient care as well as increasing efficiency," says Pat Stack, vice president for performance improvement at the 496-bed hospital.
"We weren’t an inefficient hospital. Our average length of stay was 4.1 days. We didn’t make the changes because we had a problem but because we had an opportunity to become more efficient," she says.
A key component of the model is the new role of clinical care coordinator, which combines some of the responsibilities of the case manager and some elements of the charge nurse or team leader role. The clinical care coordinators are responsible for validating patient status on admission, ensuring that patients receive tests and procedures in a timely manner, and discharge planning.
The clinical care coordinators in the emergency department work with physicians to ensure that patients are in the right status. When patients are admitted, the unit-based clinical care coordinators make sure that patients receive the recommended tests, take the lead in the discharge planning process, and spend time with patients and families to find out the information needed to create an effective discharge plan. They can call in a social worker if the patient or family has social or economic issues and complex discharge needs.
"The clinical care coordinator is the go-to person for patients, particularly in the area of discharge planning. In the past, we had a lot of activity on the front end to assign patients to beds and a lot of activity at the last minute. Now we start discharge planning at admission so there are no surprises and the patient and family know the anticipated discharge date and discharge destination from the beginning," Stack says.
Clinical care coordinators cover the hospital 24 hours a day, seven days a week. They are assigned by unit and are responsible for between 15 to 20 patients depending on acuity. Those on the night shift cover multiple units.
The hospital kept the utilization management role but removed it from the clinical care coordinator responsibilities. "The utilization management nurses are still responsible for concurrent reviews and compliance," she says.
Each day, the clinical care coordinators facilitate what they call a Status Now Action Plan huddle during which the multidisciplinary team discusses each patient’s discharge plan, what tests and procedures are pending, and what barriers could prevent a timely discharge. The team assigns one member to make sure that schedules for procedures are expedited so the patient can be discharged on time.
Creating the new roles and getting staff buy-in was a challenge at first, Stack says. "There was some skepticism about how it would work. We spent a lot of time developing the role and recruiting people to become clinical care coordinators," she says. Some of the clinical care coordinators are experienced case managers. Others are clinical experts in specific areas but have not been case managers. All of the clinical care coordinators went through four weeks of intensive training before taking on the role.
As part of the performance improvement efforts, the leadership team picks a system to improve and every clinical unit uses Lean methodology to work on how to improve the process on their own unit. Every unit has a frontline leader trained on performance improvement who spearheads the effort with the support of an operational coach. Every other Tuesday, the executive team visits every inpatient unit to check on the progress.
"The idea is that we want everybody to work on local improvement. We want them to work in-depth on areas where they have total control. We are looking at the individual unit projects to determine which can be rolled out housewide," Stack says.
For instance, the first project aimed at reducing length of stay from the time the discharge order was issued until the bed was available for the next patient. "Some units started to focus on areas outside of their control, like having environmental services come in quicker, but we wanted them to concentrate on things they could improve," she says.
The team on the mother-baby unit created a "Ticket to Ride" program that allows new mothers to pick the time they want to leave. "We don’t want to be perceived as pushing patients out before they’re ready, but we want to reduce variability," Stack says. The staff found that almost all of the new mothers wanted to leave during the day shift. As a result, the hospital was able to reduce the evening nursing staff because there were fewer patients on the unit.
"We look at the impact these projects have on one unit. On one unit, it might not be significant, but if we take it housewide, it makes a big difference," she says.
The hospital also implemented technology that incorporates information such as projected length of stay, tests, and procedures into the bed board system and gives the staff real-time access to everything that is scheduled for each patient each day and the anticipated discharge. The information is on the bed board in the nurses’ station as well as on all the computers and mobile work stations.
"We had a good bed board in place that allowed us to follow processes like bed assignments and anticipated discharge. With this new technology, we also can keep track of what is going on with the patient and track the anticipated length of stay. The clinical care coordinators can look at the board and see what needs to happen before a patient can be discharged, but it does more than that," Stack says.
For instance, schedulers can set priorities for procedures depending on when the patient is expected to be discharged. It allows physicians to see when their patients are going to be off the unit for procedures and schedule a visit when they know the patient will be in the room. If a physical therapist needs to spend time with a patient, he or she can block off a period of time and ensure that the therapy session won’t be interrupted.
"The technology has been an aid in our efforts to improve efficiency, but it’s only part of the solution. We’ve also had to transform the culture of the hospital. We have created a workforce of problem solvers. People now are conscious of the fact that patients are waiting for services. Even though they are in the bed, patients want to be cared for efficiently," she says.
