Friday, July 3, 2009

Kaizen 2: A message from Dr. Hinman

I received this letter written by Dr Priscilla Hinman. She describes her experience at the June Kaizen. With her permission I am posting it below.

For those of you who would like to learn more about Lean and CCHS, we have scheduled a two hour Lean/Kaizen introduction to Kaizen 3 for Monday July 13th at 11:00 AM at CCRMC in Building One, Conference Room One.

The report-out for Kaizen 3 is scheduled for Friday July 17th at 10:00 AM at CCRMC in Building One, Conference Room One.

These meetings are open to everyone. The introduction and report-outs for each kaizen event are also video-taped and placed on CCHS-iSite.

Be well,

Below is Dr Hinman's letter:

"I wanted to fill everyone in on this process that many of us just participated in. The process started some time ago in an effort to reduce CHF re-admissions. I believe the strongest driver of it is the specter of financial penalties for CHF re-admissions. There was a kaizen a couple of months ago which initiated changes, the most important of which from Am Care perspective was a CHF nurse case manager in Martinez. They also focused on coordinated patient education starting with admission and continuing every step of the hospitalization.

Our June group took up where they stopped, completing the transition from in-patient care to out-patient care. The first thing we did was a "waste walk". We went to the clinic and the inpatient floors and observed processes. We identified various kind of waste, from excessive walking, over inventory, over processing, etc. We then divided into 4 teams of 3 -4 people, in patient vs. Am Care (RHC represented Am Care) and develop ideas that came from the Waste Walk.

There was a multidisciplinary team which instituted multi-disciplinary rounds in the hospital, to initiate discharge planning at inception of admission, including social services, pharmacy, nursing, medicine. There was a Pharmacy/Meds team to help with drug interactions, etc. But also to help resolve insurance, formulary issues. There were out patient groups: Linda (Richmond clinic charge nurse) was part of hospital to home transition, and worked mainly on replicating the CHF nurse role for RHC and Pittsburg. The CHF nurse will get the patient information and follow up with the patient within 48 hrs of discharge, help the patient with pharmacy problems and transportation, etc.

Our out-patient groups produced a patient educator format for the CHF nurse, and patient instructions which divide clinical symptoms up into Green, Yellow, Red (like the asthma action plan form), and a clinic intake and discharge form for nursing. The nurse on intake will fill out the relevant data with expanded questions about the chief complaint and symptoms. The provider after the visit will check of boxes ordering any necessary lab, x-ray, and patient ed or dietician referrals, and can request an emphasis on home weighing, salt intake, activity, and contact instructions for Yellow Zone/Red zone. An LVN or RN will do the discharge.

Follow up appointments within AmCare were said to be fixed in the last Kaizen (May), Supposedly it is working, and I intend to follow this up with the Martinez FMC folks.

My role focused on the actual provider visit, and transfer of medical management information from in-patient to the FNP or MD seeing the patient post d/c. After watching a provider in our clinic spend 12 minutes with a DMC discharge patient, and 26 minutes with Up To Date, and calling consultants to determine a management plan appropriate to that particular patient, the problem was elucidated. With the help of Mitch Applegate I came up with the following remedy, at least for CCRMC: The new CHF Nurse referral form filled out by discharging resident was modified anew to contain specific reminders of information for the discharging resident to include in the discharge summary.

I won't inflict all the details on you, but questions are welcome. It was a very worthwhile process, or will be if this particular method continues to roll out so all of us can participate at some point, this being the Continuous Quality Improvement aspect. We were empowered/encouraged to make actual changes while learning to work the method and the nursing part is to be rolled out Monday. Administrators and relevant staff such as patient educators came to meet with us on short notice when we had to work out a process or remove an obstacle, and in fact were very helpful. I think most of us managed to put aside our occupational cynicism (cultural (old) adaptation) to try to come up with good processes.

I did have an epiphany along the way: it felt uncomfortable at times because the provider role became quite narrow and specialized. We often think of ourselves as the center of a patient's care. However, in a system with "good value flow", nursing roles expand, and Social Service and pharmacy roles develop. Everyone plays a critical part. What is left is the actual clinical encounter. I then felt a sense of relief at the very thought of no longer having to play social worker, nurse, financial counselor, and pharmacist during the FM visit. And then I realized a provider freed from these roles could then focus on clinical issues. Boy howdy

I then became very interested in the occurrence of hospital bedside rounding, and aware that important clinical conversations take place, as collective wisdom develops into a patient specific therapeutic plan. We in the clinic often don't benefit from those discussions as we take over the management of the patient, but this is very complex information to transmit. So, although getting the dry weight, discharge weight, EF, etc., are really important, what I also want to know about are the details, the actual twists and turns of the hospital course: meds tried and why d/c'd, complications, how associated conditions such as CKD affect the management, why the patient was re-admitted and the plan to remedy the defect causing the re-admission.

The next Kaizen will be in July, and Jan will be a part of it. Although these improvements affect the care of a very limited subset of patients, improving care of CHF patients at least shows us what is possible. Please be supportive of the nurses as they implement these new processes. One thing that was emphasized over and over is that it is not about blame or assigning fault. 85-90% of the time it is a system problem that when fixed makes the work simpler and more productive. This requires that we give and receive feedback, none defensively, so the defects can be eliminated for the benefit of the patient."

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