Editor’s Note: Throughout the upcoming weeks, The Hospital Leader will feature posts from SHM’s 2016 Student Hospitalist Scholar Grant recipients describing the QI projects they conducted as a part of their grants. Applications for the 2017 grant are now open at www.futureofhospitalmedicine.org/grant and will close on January 11, 2017.
This is the second in the series from medical student Joseph Moo-Young.
Before entering the University of North Carolina (UNC) School of Medicine, I learned about quality through the lens of an engineering student. The engineering curriculum included a course in Lean Six Sigma methodologies, and the problems we solved focused on industrial processes, from injection molding to yarn manufacturing.
When I discovered that hospitals used similar methodologies to improve clinical operations, I realized the wealth of opportunities available to apply quality improvement (QI) principles and methodologies to healthcare processes.
My clinical skills instructor at UNC, Dr. Kathy Bradford, happened to be one of the major QI champions at UNC Children’s Hospital, where she led a project to reduce discharge times on the general pediatric inpatient services. With guidance from co-mentors Dr. Ria Dancel, a medicine-pediatrics hospitalist, and Dr. Francisco Sylvester, chief of pediatric gastroenterology, we formulated a plan to reduce discharge times for pediatric gastroenterology inpatients. The strategies centered on changing the style of rounding and using standardized discharge criteria checklists to meet the goal of a 1 p.m. discharge.
Perhaps the most difficult part of the project was gaining initial buy-in from stakeholders, including attendings, residents, and nurses. With the support of QI champions such as my mentors, I spent my first week gathering the perspectives of the team. As my understanding of the process grew, I began collaborating with stakeholders for their suggestions on how to improve it with targeted interventions.
By engaging stakeholders in the process, I was able to alleviate many of their concerns and elucidate which patient populations to target with the discharge checklists. Performance data on the unit was useful for highlighting areas for improvement to the team, as well as the potential benefits of change.
The team agreed to replace their table-rounding process with walking rounds as a method of improving quality and placing earlier discharge orders. Discharge response time was measured as the difference between when the discharge order was placed in the EMR and when the patient physically left the hospital unit. The goal was for discharge response times less than three hours, with orders placed by 10 a.m. during morning rounds.
While some stakeholders eagerly implemented the improvement strategies, others were more reluctant. Framing the changes as simple, low-stakes, adaptable, and reversible helped to gain the buy-in of late adopters. For example: “It will be a small, experimental change we can try out for just this week. If it works well, we can continue, but if not, we can easily go back to the way you prefer.”
Initially, the walking rounds appeared to be achieving their intended purpose. The residents and attending would discuss the care plan outside the patient’s room, then enter as a team to discuss it with the patient and their family. The problem was, these rounds took longer, leaving residents less time for the morning work they had to complete before noon conference.
As a solution, the teams began to round completely in the patient’s room, discussing the care plan in the presence of the patient unless there was a compelling reason not to. The time spent rounding per patient decreased, and, as a bonus, face-to-face time with the patient increased.
For me, this mini-improvement cycle demonstrated the importance of continually evaluating and improving processes, while seeking feedback during the QI process. For example, one component of the project was to develop standardized medical discharge criteria checklists for the most common inpatient pediatric GI admission diagnoses: constipation, ulcerative colitis, Crohn’s disease, and pancreatitis. Whereas I had originally planned to monitor the entire pediatric GI service’s discharge performance, my mentors suggested also monitoring the four diagnoses and comparing them to their historical baseline, so that we could isolate the effects of the checklists.
Being flexible with shortcomings in the interventions improved the work we did. More importantly, it gave residents a greater stake in the project and helped to achieve their buy-in, as they were able to see the value of their contributions.
Now that my QI project has come to an end, I have begun some preliminary analysis. For June and July 2016, 14 out of 50 discharges occurred before 1 p.m., and the average discharge response time was 1 hour and 44 minutes. Compared to the same period in 2015, 15 out of 51 discharges occurred before 1 pm, and the average discharge response time was 1 hour and 20 minutes. The rounding interventions appear to have had little to no impact on overall discharge time, but data for the discharge checklists is still being processed. In addition, results for the balancing measure of length of stay showed improvement, where excess length of stay days declined from 1.27 to 0.90 days.
While it will not be possible for me to monitor rounds every day, I hope that I have given the team some tools to better understand and take ownership of the work they do, and the incentive to continue to work toward improving the discharge process.
In terms of applying for the SHM Student Hospitalist Scholar Grant, the biggest lesson I learned was the importance of concise writing. I initially struggled to distill the project’s most important components down to one page.
This project has been a great opportunity for me to learn about many different topics, from process improvement and Lean Six Sigma, to stakeholder buy-in and organizational psychology. I hope that I can continue to grow in my knowledge of quality improvement to better serve my patients in the future.