Critical Path Network
Projects improve patient flow, shorten LOS
Six Sigma initiatives aim to improve processes
Two Six Sigma projects at Wake Forest University Baptist Medical Center in Winston-Salem, NC, focusing on improving patient flow have streamlined the processes for transferring patients from the acute care unit to the inpatient rehabilitation unit and nursing homes.
The first project, designed to improve the process by which patients are referred to acute rehabilitation, cut almost two days from the process.
The second project, which still is under way, aims to improve transfers to skilled nursing facilities.
"We want everybody to be in the acute care setting the appropriate amount of time. Our Six Sigma projects look at the process to identify issues that are barriers to moving patients to the next level of care in a timely manner," says Patricia L. Mabe, RN, MSN, CCM, ACM, director of care coordination.
The care coordination department has about 98 FTEs including case managers, social workers, clinical documentation management nurses, and utilization management nurses. The case managers and social workers handle patient flow and discharge planning.
The Six Sigma teams include all appropriate hospital staff for that particular project.
"It's very important to have the staff that does the work involved in the project as we look at every step in the process to determine where the roadblocks are and what we can do to eliminate them," Mabe says.
During the rehabilitation transfer project, the team set a goal of reducing the amount of time the process took from referral to acceptance to rehabilitation.
The team started by mapping the process for admitting patients to rehabilitation and brainstorming on how the process can be improved.
"We decide, as a group, what we can work on now and what will take longer. We've found that it's really important to be focused on what can be controlled," Mabe says.
The team discovered that some patients, particularly those who were not on the trauma or neurosurgical floors, were staying in the hospital after they were medically ready for transfer to rehab. They were delayed because the physical therapy or occupational therapy evaluation had not been completed at the time of the referral.
"Some people were calling the rehabilitation admission consultant at the same time they called for a physical therapy evaluation. Others waited for the physical therapy evaluation to be completed to call the rehabilitation admissions nurse. The goal in Six Sigma is to eliminate process variations. In this case, we got everybody together, looked at the variations in referral processes, and developed a consistent process," Mabe says.
Checklist developed for CMs, social workers
The team developed a checklist for the case managers and social workers that includes obtaining physical therapy or occupational therapy evaluations before calling the rehabilitation admissions nurse to certify that the patient is ready for transfer.
"We have patients all over the hospital who are transferred to acute rehabilitation. The trauma staff and staff on the neurosurgical unit handle so many of these patients that they are familiar with the process. For staff on the general medical and oncology floors, it is very helpful to have the checklist," Mabe explains.
Other initiatives included streamlining the assessment conducted by the rehabilitation admissions nurse and changing the sequence in which the insurance companies received information needed to certify the rehabilitation transfer.
Now, instead of waiting for a physician to sign a discharge order, the department requests certification from the insurance company as soon as the rehabilitation admissions nurse completes the evaluation.
Another Six Sigma team is working on a project to reduce the length of stay for patients who are being transferred to skilled nursing facilities.
"We know that our length of stay for these patients is longer than expected. Our project is focusing on why these patients are staying longer and eliminate the barriers to transferring them," Mabe says.
A team that includes case managers, social workers, unit nurses, and physicians examined data from the general medical population and determined that many of the patients with longer than expected stays were being treated for urinary tract infections and they were staying longer because the final results of urine or blood cultures were not available.
When the project began, the laboratory was reading all the urine cultures in batches. Simply changing the process so they read the oldest cultures first helped get the treatment team the data they needed to discharge the patient in a more timely manner.
"This simple process change came from having data and knowing where to look," Mabe says.
Other patients were staying in the hospital because the discharge summary for the nursing home was not ready.
The team has worked with the physicians to see that the majority of the discharge summaries are completed the day before the patient is expected to be discharged, rather than after the discharge orders are signed. Now, they add any necessary information on the day of discharge.
"Our physicians are very cooperative, but they are often prioritizing 10 things. We are working to help them understand that sometimes what we need to facilitate a discharge is important to patient care. If they don't complete the discharge summary, it will delay things in the end. We need patients to be discharged so that patients waiting for a bed may be moved. It's a domino effect that impacts the entire hospital," Mabe says.
The team brought in nursing home and ambulance service representatives to brainstorm on solutions to problems with transfers.
"We listened to their challenges and talked them through. With each of the little fixes, we tried to have all of the stakeholders' needs addressed. We looked at what we could do to help address the challenges they face," Mabe says.
Since there only is one ambulance company that transports nonemergent patients, waiting for transportation was holding up patient transfers.
For instance, ambulance company representatives told the team that it couldn't handle a lot of requests for patient transports late in the day.
Among the solutions was to alert the ambulance service as soon as the physician says a patient is likely to be ready for discharge and the facility has a bed and get that patient on the ambulance company's pending list.
The skilled nursing facility representatives reported that discharges late in the day created a challenge for their staff who had to stay late to complete the admission paperwork.
"We are trying to get them the information about the patient as soon as we have it. If they have the discharge summary, they can order the drugs that the patient will need and have them on hand when the patient arrives," Mabe reports.
The team also tackled ways to cut down on delays caused by family resistance to transferring their loved one to a nursing home.
"We have a very short window of time because these patients are typically in the hospital less than six days. We don't want to push them. We try to educate them and let them know the anticipated time frames so they don't expect for the patient to stay in the hospital until they can decide where the 'perfect' place will be and so they will have multiple opportunities to have their questions answered," Mabe says.
One tactic is for physicians to tell the family in the beginning when they anticipate that the patient will have a skilled nursing stay. The idea is reinforced by the staff.
"Patients and families want to hear it first from the physician, not the case manager or social worker. We get everybody on the same page at the beginning so patients and families hear a daily echo of the same thing. As patient advocates, we want the family to hear it often so they have opportunities to have their concerns addressed in a timely manner," Mabe explains.
If family members still are resistant, the team suggests that the family spend 12-24 hours at the hospital taking care of their family member just as they would have to do at home.
"In so many cases, someone has promised their parent they won't ever send her to a nursing home. When they realize how hard it would be to take care of the parent at home, it helps ease the transition," Mabe says.
(For more information, contact Patricia L. Mabe, at [email protected].)
Two Six Sigma projects at Wake Forest University Baptist Medical Center in Winston-Salem, NC, focusing on improving patient flow have streamlined the processes for transferring patients from the acute care unit to the inpatient rehabilitation unit and nursing homes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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