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Care Team Rounding A3

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by

Stephen Badger

on 8 February 2013

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Transcript of Care Team Rounding A3

Finally The Proposed Solution What's the problem? Care Team Rounding Current rounding process is not patient centered. This results from uncoordinated care, inefficient process/workflow and poor communication. This can cause adverse events, poor patient outcomes, and patient, staff and provider dissatisfaction.

Scope:
Start: patient on floor with written orders
Stop: patient discharged from hospital Nursing Gap Analysis No Consistent Rounding Process Future State Patient Centered Possible Solutions 1, Current State 2, 4 3, Who:
- MD
- RN (Primary
- Pharm
- CM
- Charge RN Hallway:
- RT
- PT
- Social Work
- Dietary Need:
- Appointed times
- Duplicate teams
- Physician extenders
- 2 docs per unit or 1 doc for all 30 pts
- Separate admitters vs. rounders (docs) How:
-Team members with customer service skills
-Team members with ability to think on feet/outside the box
-People with team based skills
-Training on the new model
-Budget $$ for resources/people
-Change workflow to reallocate resources
-All team members geographically assigned
-Arm pharmacist with a WOW to answer questions
-Flexibility of team
-Team focus/centered on patient/new approach
-One family of patients - one care team family 15 pts/team Who:
Core Team
-MD
-Primary RN
-Case Manager
-Pharmacy

Other Team Members
-RT
-PT
-Social Work
-Dietitian Charge RN could coord. How:
-Primary RN: presents the patient - abnormal labs/meds/pain/issues and updates the whiteboard
-MD: Plan of care and eval
-Case Manager: Discharge needs/plan/barrier
-Pharm: Reviews current meds and makes recommendations, med/rec Floor Based Model with rounding time windows Metrics:
-Patient Satisfaction
-Length of Stay
-Whiteboard audits Tools:
-WOW
-Script for primary RN
-Patient Letter -> Admit packet
-Training materials
-Video
-Rounds outline Who:
Bedside portion
-CM
-Primary RN
-MD
-Charge RN
At the door before bed
-CM
-RN
-MD
-PT
-Charge RN
-RT
-Dietary
-Social Work
-Pharmacy How:
-Pre-work (each team member)
-Specified time of day (Full team)
-Let patient know time range
-Specified duration of rounds (overall & per patient duration 2-4 min)
-Rounding template
-Full team huddle outside patient room
-Discuss 1 patient at a time
-Bedside Team Round
-Start with core and add as necessary
-Scribe orders during round (only pertinent assessment)
-Whiteboard update, recap "to-do's" in room together
-Leave room
-"Second verse..." Needs:
-Geographically assigned: pharmacist, RN's, and MD's (1 MD/floor/unit?)
-Identify rounding times/unit & bed (schedule)
-Education/Training (teams, process, customer service)
-Rounding template(s) - prep, round, follow-up
-Clear goals/expectations
-Metrics
-Accountability
-Policy/procedure development
-Tools - EPIC template - added notes throughout shift
-To do it!!! Now! Who:
Bedside:
-MD
-Primary RN
-Case Manager
-Social Worker
Other:
-PT
-RT
-Pharmacy
-Nutrition How:
-Each unit 2-3 hospitalists
-1-2 CM's per unit (based on census)
-1 social worker, PT/PT asst., pharmacist, RT, and dietitian per unit
-Limit 2 RN's/hospitalist (continuity of assignment throughout week/stay)
-EPIC IDT Rounding Report/Template
-Pulls in last filed data/notes for multi-disciplinary teams (i.e. dietary, wound care, PT, etc.) Rounding Times:
-Pre-bedside: (2-3 min)
-All disciplines meet outside room and discuss IDT template
-RN gives SBAR, facilitates, focus on exceptions and barriers to discharge
-Start of day RN reviews IDT bedside rounding expectations with patient
-Bedside:
-MD facilitator/introductions
-Discussion/assessment/questions of patient
-Plan of care shared with patient
-RN (or appropriate care team member) updates whiteboard with info
-Post bedside debriefing:
-Order entry (explore possibilities within EPIC to pend orders for MD to sign after bedside)
-Proceed with plan of care Difficult Effective Standard
Rounding
Template (paper)
-Roles & Responsibilities EPIC Note A-Team Pharm D Change MD Comp EPIC Rpt for Rounds RN Geographic
Assignments Rounding
Times MD Geography
Assignments No Single Forum for Coordination MD's not Communication with one another Care Team is not prepared Team members not available Team members with different workflows Different responsibilities for patient care Everyone works in silos No teaching or training No set standard for rounding Don't understand importance Expectations are not set/clear No vision of collaborative care No designated leader to build vision MD's & RT's have patients on different floors Random for MD's Equalized work load for RT's Assignments not made based on patient needs MD's RT's No Agreement on care plans by diagnosis Culture of independent practice Physician leaders are not promoting MD can't be there Too many patients on different units Difficult to geographically assign Too much time Go off track Tangential conversations Not as prepared as needed EPIC tools not being used Paging System doesn't always work Different paging equipment MMC doesn't provide pagers $? No call back Not urgent Got busy Forgot Office hours/OR schedule Might not receive Technical problems No one way/# to reach MD's Different groups and individuals Personal preferences Gould is easy - call one number Other MD's are difficult because
no one is tracking preferences RN as "Middle Man" RN not evaluating specific problem New RN Too busy/overwhelmed Unclear plan of care MD didn't communicate well with RN No consistent way of communication MD preference Reluctance of MD's to talk to each other Personality History/Culture No timely note in EPIC No expectations set Not reviewing the charts (both MD & RN) Rounding too early Docs come early @ 0730 Nothing else to do/start of day Doc day starts @ 0600-0700 Rushed Late start - specifically float RN Style Chart review vs. patient seen differs New patients vs. established patients RN Handoff Too much or too little info Different styles No standard report SBAR not followed Lack of education/ re-education Multiple interuptions Patients waking up Meds, vitals, breakfast, procedures No set time for family/care team interaction Codes If we....

-Assign MD's geographically


-if MD, there



-if better rounds Then we....

-ID rounds could happen with MD input


-IDT rounds would be more valid and more productive


-better patient care Problem: still missing patient input If we....

-If the AM Triagist did the full admit in the AM


-If we had admitting Hospitalists


-If we had buy-in to a "patient centered" model from all stakeholders (i.e. A-team, rounding team, EVS, Lab, Food Svc, etc.)

-Don't have the tools to do the job


If we come together to round w/ MD Then we...

-Free up Rounder to do IDT rounds


-Rounders could see more patients
-Rounders could be geographically assigned

-Process will truly succeed



-We do not attempt


-Orders can be entered/scribed in real time
-Standardize template for physician notes
-Team note?
-IDT
-Templated If we...

-Had a standardized template


-Local control


-Prepared prior to rounds/ info reviewed


-Appointed physician rounding times


-If physicians were in the same room at the same time Then we...

-More efficient w/ EPIC
-Save time

-Floors could make changes quickly to team content


-Rounds would be more efficient


-Could get away with current process
-Communicate time to care team, pt., family

-Communication problems would decrease If we...

-Change MD compensation schedule to reward IDT Rounding

-Have more consistent rounding time

-Have proper staff
-All disciplines geographically assigned - Pharm, RT, MD, PT, RN, CM

We could standardize a rounding team/ identify the components Then we...

-Would get MD buy-in


-We're prepared & ready when rounds occur

-Proper team
-Proper rounding configuration
-Ability to establish a time


-Compose a rounding team If we...

-Create a rounding team in patient room utilizing the whiteboard and have a bigger interdisciplinary team outside the room Then we....

-Increase patient satisfaction
-Decrease # of calls
-Team and patient knows the plan of care
-1 forum
-Current information shared Hospitalists Case Management Get patient list with
overnight admits Review patient
charts (0-1hr) Variation: all/none/some Go to floor Variation:
-Go see really sick patients first
-See new admits first
-Skip ICU b/c they are doing shift rpt
-Start from the top going down Review Chart Variation:
-1 pt. at a time
-All pts on that unit Find RN Variation:
-Call RN
-Ask Unit Secretary
-See them Evaluate Patient Variation:
-With RN
-Without RN Talk to Family Variation:
-Phone call now or later Document -Orders
-Notes
-Consults
-Case Mgmt Variation:
-Now or later Talk to CM Variation:
-Now or later -Demanding family
-AMA
-Admission
-Surprise discharge
-Patient deteriorating
-Pages Interruptions: Start: 0645 RN to RN
bedside report Change whiteboard Template/consistent
format EPIC review RN notes Patient
Assessment Med pass MD rounding Patient
discharge -Safety check
-Full assessment
-Med rec -Fall risk
-Sepsis
-Braden
-Restraint
-Core Measures Charting Toileting/
bathing Toileting/
bathing Med Rec/
Immunizations
each shift Family at
bedside Phone calls Procedures PT/Ancillary Charge RN
handoff Break
coverage Changing Iso gowns Pharm. std. Dragon Streamline assessment & doc. Schedules Patient
change in
condition More frequent
pt. visits charting ACU check Meds Lunch IDT Rounds Toileting/
bathing Charting IV starts D/C & Admit Phone calls
for d/c needs Dressing
changes Rounding w/
consults Pt. teaching/
care plans Rounding/
I's & O's Report Change
whiteboard EPIC
&
Phone Calls MD Rounds Communication forums/methods Patient Assignment
to Case Manager IDT Rounds
-Prep & Rounding IDT Round Attendees:
-Charge RN
-Social Services
-Case Mgr
-PT
-RT
-Dietary New Patient Within 24hrs of pt. admission:
-CM Initial
-Midas/Interqual review Initial CM Assessment done
w/ patient/family Daily MD/CM Rounds:
-Discharge POC discussed
-Ongoing issues Communicate POC w/ nursing
as indicated. For example:
-Complicated discharge needs
-Nurse follow-up need Concurrent reviews daily/
every other day Reassess discharge
plan w/ patient/family
every 2 days and update notes Evaluating barriers to pt's
flow to discharge (i.e. consults
not done, tests not done. Intervene as needed SNF transfers Day of discharge - arrange
for DME/Home Care IDT Rounds MD/CM
Rounds -Coordinated -Clear Responsibilities -Efficient -Prepared -One plan that everyone knows -Clear Expectations -Low cost -Patient involvement -Options -Quality care with a smile (good customer service) -Family involvement -No repetition -Timely communication/availability -Less chart work -Cultural awareness -Honesty -Clear communication -Education is coordinated and understood Communication -Break in communication
-Timeliness of orders being placed after discussed (i.e. discharge orders, meds, etc.)
-When the nurse is available, the MD is not or visa-versa
-MD comes and goes without seeing the RN
-MD does not wait for nurse to round on patient
-MD shows up on floor. You tell the patient that their MD is there. Then the MD leaves without seeing the patient
-Satellite charting by MD - no phone call to RN (i.e. MD writes order to transfer patient to higher level of care without telling RN)
-Primary and consultants waiting for each other to do the discharge or have consultant approve for discharge Unclear Plan of Care -Note not made for hours after the MD left. If you want to update the patient, there is no note yet
-Not knowing plan of care
-Notes not placed by consulting MD. Only verbalized to nurse. Hard for hospitalist to plan care without written documentation.
-MD changes patients pain med without telling patient or RN
-Too much info. Don't know what is important and forget to give that info Hand-off -Information being lost in hand-off
-0930 RN/Case manager rounds
-Day 1 for Charge RN is different than Day 2 or 3 based on familiarity & time spent w/ patient
-MD asking what went on during the night and the day nurse not informed
-Not familiar with patients
-RN not reading progress notes
-Admitting patient to the floor that may not need a higher level of care. Differences in work flows/time mgmt -Informational needs differ between case managers
-MD does not want to be bothered unless he sees patients or read chart first
-MD's rounding during med passes
-Inconsistency in rounding time of MDs - some 0900 and others 1900
-With all our busy schedules/time, it's hard to manage time to all get together including bedside nurse
-More calls to hospitalists between 4-6pm knowing that night hospitalist may not address patient issues.
-When to downgrade - MD vs RN opinion
-MD rounds at end of shift
-General rounding time of MD's bw 0900-1300 -Critical Care: PT, RT, Dietary
-Telemetry
-Total Joint: PT Bedside Rounds Core Team - at bedside Process: -Bedside RN sets rounding expectations with patient/family - verbal and written letter -Attending
-Primary RN
-Case Manager
-Pharmacy Unit Dependent Implementation Plan Pre-Rounding Units: Oncology & Renal Tele (2 month pilot) Training:
-All nurses (Rochelle, Leslie, Brenda or June)
-How to present the patient (HealthStream)
-Schedule and teach RNs
-End of February
-Pharmacy training
-CM training - Sherry to talk to Carol re: 7 day coverage Rounding Times starts at 0800~1000:
-Pre-bedside outside the room: (2-3 min)
-RN gives SBAR (tool), facilitates, focus on exceptions and barriers to discharge
-CM reports discharge plan, barriers to discharge
-MD discusses plan of care
-Bedside:
-MD facilitator/introductions
-Discussion/assessment/questions of patient
-Plan of care shared with patient
-CM updates whiteboard with records homework for ancillary
-RN scribes orders -Night RN fills out "Patient Presentation Tool" and reviews during bedside report (to become shift to shift report both day and night) EPIC - tool for pulling info on "Pt. presentation tool" -CH RN - will help coordinate and run interference for bedside RN presenting Needs:
- 2 WOWs
- Patient letter
- Rounding template Metrics:
-Audit Tool
-Whiteboards
-Usage of presentation template (appropriate rounds)
-LOS
-Readmission rate
-Falls
-Core Measures
-Med errors (Med errors/pt day)
-Time of discharge orders
-Patient satisfaction
-Staff & Provider satisfaction - Survey Monkey (pre and post)
-Timing of rounds - CM
-# of MD pages -Ancillary writes immediately after seeing patient Pilot Go-live: March 6th WIIFM:
-Eliminate IDT Rounds
-Improve Communication
-Decrease phone calls to MD
-both day and night MD's assigned geographically Mandatory Staff Meeting and stand ups After go-live - Weekly Debrief - plus/delta -Mtg with nursing leadership to determine education plan - Rochelle, Audrey, Stephen
-Develop education
-RN - Rochelle, Leslie, Brenda, June, Lisa
-CM - Sherry
-Pharmacy - Pam will create checklist
-MD - Audrey
-Change Rounding Presentation Template - Sherry, Stephen, Rochelle, Niazi
-Change patient letter - Stephen, Audrey, Niazi, Leslie, Brenda
-Scripting verbal education for patient
-CM checklist - Sherry and Dan
-Develop standard work for PT communication
-Make video (smaller workgroup)
-Script - Friday 25th - Rochelle, Audrey, Niazi
-Present at Charge RN and nursing forum - Feb 19,22, 25 -Post bedside debriefing:
-Order entry (explore possibilities within EPIC to pend orders for MD to sign after bedside)
-Proceed with plan of care Next Steps: -MD/Family Time 1500-1700 Care Team Rounding
Full transcript