New care model transforms facility
'Collaborative care' decreases LOS
ThedaCare's Appleton (WI) Medical Center has cut its average length of stay by 20% and improved quality, safety, and patient satisfaction by transforming the way it provides care. This new approach, which it calls "Collaborative Care," has been piloted in the hospital's redesigned general medicine unit since February 2007. Based on the program's success, ThedaCare plans to begin rolling it out to other facilities.
The model was created internally, "from the vision of our nursing leaders," says Mary Beth Heatherington, RN, CSN, chief nursing officer. "We started to hear from our physicians that we didn't have continuity in communications. We were working in silos — which we realized was no different than what was happening across the country — and decided we had to find a better way."
Reports from the Institute of Medicine about errors and health care costs, as well as a system-wide move toward Lean methodology, informed the changes, she continues. "Lean tools and processes were used as a framework to develop the model," she explains.
The experimental unit is the hospitalist unit, Heatherington continues. "Their goal is to provide more leadership, and this is perfect because they are here '24/7,'" she says. "We had to involve them in the whole building process, so we had two of the group as primary builders of the model — so others would see they were on board."
The model, she continues, was developed by frontline clinicians. "It started with value stream mapping [value stream mapping is a Lean technique used to analyse the flow of materials and information currently required to bring a product or service to a consumer] then three vertical value streams, followed by seven rapid improvement events," says Heatherington.
"Our cornerstone goals were to increase quality of care while providing that care at a lower cost," adds Shana Herzfeldt, RN, BSN, supervisor of medical services for the unit. "We redefined the nursing role: Our RNs act more as case managers; we look more closely at patient stay and how we can progress our patients rather than being tied to bedside tasks." In order to accomplish that, she notes, LPNs now do more task-oriented activities such as passing meds and changing dressings. "Clinical nurse specialists are really doing personal care for the patient," she says.
"The RN actually becomes a coordinator of care," adds Heatherington. "When the patient is admitted they meet with the pharmacist and the physician, to create a 'problem' list and a plan of care together."
Collaborative rounding is added
This collaborative process extends to rounding. "It is now a coordinated bedside care conference," says Herzfeldt. "We meet outside the patient's room, and discuss the plan.
"Something else that is unique about this process is that we used one of our Lean tools — the Jidoka framework — which is a method for preventing errors," says Heatherington. "It requires the nurse and physician to stop and ask if everything that was ordered has been ordered, and if not, find out why. It also identifies the highest 'hitters' to target for improvement." Heatherington says that as a result of this framework, "we have had a reduction in errors."
Getting the rest of the staff on board with this new model "took a good six months," says Herzfeldt. "We had six weeks of off-site orientation for this unit because it was a first," she says. "The staff were chosen through an interview process, knowing they needed to be flexible because of what their roles would entail."
Focus was both on the process and the computer system, she notes, since an electronic medical record is now being used. "This way, all the caregivers can see every document on every care plan, rather than seeing care in silos," she explains, adding that physicians went through computer training as well.
The actual physical layout of the unit was changed as well, notes Herzfeldt. "We focused on three things — process, people, and physical environment," she explains. "On the physical side, we asserted that the less a nurse has to remember, the more efficient she will be."
Accordingly, the unit has a more open concept, with no centralized nurse station, but rather alcoves that encourage collaboration. "The unit also has nurse servers, which contain 90% of what nurses need as far as meds and supplies at the bedside — including linens, so they don't have to leave the room to go to central supply," says Herzfeldt.
Each room has ceiling lifts to prevent back injury, walkers, IVs, dyna-maps to do vitals, and computers, so documentation can be done real-time. "Every room has a bathroom with a shower, and the special flooring does not get slippery when it gets wet, so that helps prevent falls," says Herzfeldt, adding that all beds have a built-in alarm system that indicates when the patient gets out of bed — another fall prevention strategy.
The rooms also are equipped with numerous "visual cues," Herzfeldt continues. "When doctors write orders you have a yellow light [on the 'call light' fixture outside the room]; when you start processes you turn on a green light, which tells the RN that orders need to be acknowledged; and when pharmacy delivers meds, they turn on an orange light. In addition, if specimens are needed, there are colored magnets that can be placed on the whiteboard (which is in every room) to identify the type of specimen needed."
Patients have been enthusiastic about the new model, says Heatherington. "We have gone up about 30% in the number of patients who give us a 'top-box' rating on our patient satisfaction survey," she says. What's more, she adds, "Our quality results have improved in terms of compliance with CMS bundles."
Collaborative Care will be the new model of care for the system, she continues. "We've developed the model of care and now the renovation that supports it," she explains. "And what we spent is not necessarily more expensive than what you would spend for a traditional unit."
[For additional information, contact:
Mary Beth Heatherington, RN, CSN, Chief Nursing Officer, or Shana Herzfeldt, RN, BSN, Supervisor of Medical Services, General Medicine unit, Appleton Medical Center, 1818 N. Meade St. Appleton, WI 54911. Phone (Heatherington): (920) 735-7333; (Herzfeldt) (920) 738-6427.]
ThedaCare's Appleton (WI) Medical Center has cut its average length of stay by 20% and improved quality, safety, and patient satisfaction by transforming the way it provides care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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