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BC Ministry of Health Clinical Care Management recently
launched 48/6 Model of Care, a quality improvement init...
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QF14 Storyboard Winner - Improving Patient Centred Care in the Critical First 48 Hours of Hospital Admission


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This was a winning storyboard from Quality Forum 2014. It was presented by:

Pearl Leung
Senior Consultant, Strategic Transformation
Fraser Health

Published in: Health & Medicine
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QF14 Storyboard Winner - Improving Patient Centred Care in the Critical First 48 Hours of Hospital Admission

  1. 1. Background 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 compliance. 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 measurement. Issue/Problem 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. Implementation challenges 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 is needed. 1. Clinical Care Management Practice Statements for 48/6 Long Version v3 (2013) Change Approach Structure 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. Change model 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 documents; Clinical Program leadership was consulted to ensure that operational resource is in place to: e) Provide Reinforcement to sustain the change post implementation. Change Processes Documentation Standardization 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. People Practices 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 planning. 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 down approach. 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 implementation activities. Education/Training 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 learning experience; 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/ program leaders. 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