QF14 Storyboard Winner - Improving Patient Centred Care in the Critical First 48 Hours of Hospital Admission
BC Ministry of Health Clinical Care Management recently
launched 48/6 Model of Care, a quality improvement initiative.
This model addresses six key care areas of functioning
through documented screening, assessment and care
planning within 48 hours of decision to admit for seniors (70+).
By September 2014 all health authorities must be in
Driven by the vision of a powerful end goal of “seamless care”
patient experience, with guiding principles such as:
1. Put the patient/client/resident first,
2. Standardize for quality care,
3. Ensure availability and utilization of information, and
4. Be one care team;
Fraser Health (FH) took up the challenge and exceeded it by
applying the model to all adult inpatient (17+), creating a more
consistent, standardized, holistic approach with in-depth
information on pre-hospital function, more specific
documentation, and improved communication and
In Canada, 30% of seniors admitted to acute care will be
discharged at a significantly reduced level of functional ability
and most will never recover to their previous level of
independence1. The 48/6 Model of Care offers a more
consistent approach with in-depth information on pre-hospital
function, more specific clinical documentation, and improved
communication and measurement.
According to Vital Statistic, FH has the largest senior
population in BC. This age group is expected to increase by
75% in the next 12 years.
Last year, 22% of total Emergency visits in FH were from
patients over 65 years of age. 50.3% of these visits translated
into hospital admissions, which accounted for > 59% of
inpatient hospital days. With the anticipated demographic
shift, it is almost certain that there will be an increased
demand on the health care system.
Improving patient care is foremost for health care providers,
but with competing priorities, higher degrees of specialization,
increasing fragmentation of care, shrinking resources, and
higher levels of patient acuity, such intention is constantly
being challenged. Change fatigue is apparent everywhere.
Treating the symptoms of the challenges is ineffective, and
may further contribute to change fatigue. System level change
1. Clinical Care Management Practice Statements for 48/6 Long Version v3 (2013)
Engaging a vertical slice of the organization to inspire and
empower change, front-line champions were engaged to build
awareness and desire for change. Middle management was
consulted to ensure clinical program support, and senior
leadership was involved in sponsoring and steering major
decision-making only. Structure of this approach enabled project
team to be nimble and agile. Decision making was evolutionary.
Shaped and informed by front-line input, decisions were made
collaboratively at the program level and organizationally
aligned and supported by senior organizational leaders.
Using ADKAR model to assist the
change process, frontline change
champions were equipped with
training and tool kits to:
a) Create Awareness of the need for change; and
b) Promote Desire to participate and support the change;
A centralized education and training plan was created to:
c) Provide Knowledge on how to change; and
d) Foster Ability to implement required skills and behaviors
by pursing front-line feedback on challenges/obstacles
that may impede application or adoption of the new
Clinical Program leadership was consulted to ensure that
operational resource is in place to:
e) Provide Reinforcement to sustain the change post
To standardize documentation for more effective communication,
collaboration took place across disciplines and clinical programs.
Clinical experts were engaged system-wide to co-design the
clinical solution, standardizing ~1600 non-standard clinical forms
down to 5 regional tools2. In addition, Patient Advisory Council
(PAC), Integrated Professional Practice Council (IPPC), FH
Health Literacy Experts, Professional Practice and Integration
(PPI), Risk Management and Health Business & Analytics
(HB&A) were also involved to ensure that the ensuing clinical
solution are evidence-informed, meets professional
documentation and literacy standards, and contains appropriate
data points for evaluation purposes.
An early adopter group was
chosen to prototype the new
tools and processes prior to FH
wide implementation. Using a
story telling approach, the
patient’s story became the
emphasis for the change rather than a ministry mandate. A
series of workshops were provided to support the frontline
change champions. A patient advocate from the Patient Advisory
Council (PAC) was there to put the patient in the forefront of the
change. Frontline change champions were supported through
face to face weekly forums to ensure that issues or challenges
identified are resolved or escalated in a timely manner.
2. 3 out of 5 standardized tools are currently being implemented. The remaining 2 tools are in
progress and will be implemented after (June 2014).
Early Adopter Learnings
Early Implementation took place in Oct 2013. Lessons learned
were instrumental in informing system-wide implementation
2 key learnings gained are:
a) Using a positive focus (seamless care) rather than a
mandate to inspire change; and
b) Leveraging front-line champions rather than using a top
Once change champions fully grasped how the change would
impact patients, they articulated their dreams for the change,
which were subsequently used as an inspiration for all
Approximately 600 staff from the early adopter group attended the
centralized 2.25hr learning sessions. In addition to providing an
overview of 48/6 and the standardized tools, a significant portion
of the session was devoted to an interactive exercise, where
attendees from various professions were able to apply their
learnings in a case study. Evaluation of the training sessions was
gathered from those attended.
Of those responded:
81% agreed or strongly agreed that it was overall a good
88% agreed or strongly agreed that the session provided the
understanding of the new documents.
84% agreed or strongly agreed that they have an
understanding of the role of the team in the 48/6 process
Measurements and Evaluation
Preliminary audit was performed post implementation to gain insights into
process compliance. Manual chart audit ran from Oct 22-Nov 22, 2013 on
219 charts for unit patients and 136 charts for Emergency (ED) patients3.
Of the found charts4,
70% of the screening tools and 25% of care plans were completed
(within 48hr) for unit patients, and
85% of screening tools and 17% of care plans were completed
(within 48hr) for ED patients.
Time Compliance in Unit patients
Time Compliance in ED patients
A standardized location has since been identified for the 48/6 documents
in preparation for system-wide implementation. Subsequent audits should
provide a more accurate picture.
Once 48/6 is fully implemented, we will be exploring key measures for the
effectiveness of 48/6 model of care, focusing on impact rather than
compliance for the change. Possible indicators might be decrease in
hospital stays, improved patient outcomes in 6 key care areas and patient
satisfaction survey results.
Early Learnings for System-Wide Implementation
Momentum is building following the early adopter experience. In January,
8 kick off sessions (2 hours) were delivered to over 300 frontline change
champions and clinical program leaders across 11 acute sites. In addition,
to better equip the change champions in their role to inspire and support
their teams through this change, 6 half-day “Coaching Change” sessions
were subsequently delivered. During these sessions, change theories and
techniques were shared and attendees were able to practice these
techniques using 48/6 as a case study. Approximately 150 change
champions participated in the session and general feedback was positive.
Here are some comments from participants:
I liked how these tools can apply in just about any change situation
Small group work made concepts clearer and more memorable
I feel more confident on how to approach change
I was negative about this session going in but I found it very helpful and
informative – thank you!
I like how the session was done; it highlighted the issues and what tools we
can use to sort through the change ahead – great job!
A Site Director emailed after one of the coaching change sessions:
“I am sorry I missed you today but I send Wendy on behalf of the site. She says it
was one of the best “sessions” to roll out an initiative she has been to….well
done you! I will ask other site leaders to attend future sessions.”
Response has been so positive that additional coaching change sessions
are now being considered for additional change champions and site/
48/6 regional education has already begun. 7-8 centralized trainers will be
delivering over 230 learning sessions (2 hours) across the region during
February and March, 2014. There is a sense of excitement and
anticipation. Full implementation across FH is expected by June 2014.
3. These patients were admitted and discharged from ED, i.e., they were never admitted into any inpatient units
4. During the early adoption phase, location of documents had not been standardized. Care teams were asked to
integrate the new documents into their exiting process to facilitate adoption. As such, it was at times challenging for
the auditor to locate the documents.
Improving patient-centered care in the critical first 48 hours of hospital admission
Lisa Chu, Project Director; Pearl Leung, Project Manager; Jen Reed-Lewis, Organizational Development Lead
Fraser Health Authority