Case Studies

Intermediate Cardiac Care Unit (ICCU)

The ICCU's lead improvement team brainstormed ideas on where to focus improvement. Once the team members had all contributed their ideas, they multi-voted, which led them to a decision to focus on morning rounds. They learned

FIGURE 21.2. CHANGE CONCEPTS APPLIED TO A CLINICAL PROCESS.

FIGURE 21.2. CHANGE CONCEPTS APPLIED TO A CLINICAL PROCESS.

5. Reorder sequence

that morning rounds were not interdisciplinary and that the clinical team often did not know the specific care plans for each patient. This resulted in inconsistent communication to patients, families, and staff concerning the plan of the day, which in turn led to delays in discharges and transfers. After morning rounds were selected as a focus, the team brainstormed ideas for improvement. Walking rounds with all professionals—including patients and families—was suggested, as well as holding consolidated interdisciplinary rounds in the conference room, and "just forcing" people to communicate better. After the team members brainstormed all their ideas, they multi-voted and decided to test the approach of consolidated interdisciplinary rounds in the conference room. It was clear that the different clinical disciplines needed to learn to value each other's contributions to patient care and also to learn how to communicate differently.

The first PDSA cycle was conducted. This led to many subsequent PDSA cycles, each building on the lessons from the prior cycle (see Figure 14.7). The new insights about communication, professional relationships, and patient care plans were enormous. The medical director spoke frequently with the attending staff and house staff to coach and educate colleagues about the process changes that were being tested. To keep everyone up to date, the ICCU nursing director communicated frequently with all nursing staff using verbal communications, change of shift updates, and visual displays.

Plastic Surgery Section

With the specific aim to decrease the backlog for appointments by 50 percent (with a starting baseline measure of ninety-nine days), the Plastic Surgery Section lead improvement team designed tests of change for shared medical appointments, a type of medical care popularized by Noffsinger (Carlson, 2003).

The Plastic Surgery team reviewed its flowchart and fishbone diagram to see how shared medical appointments might improve patient satisfaction and clinical productivity while reducing the backlog of patients. The new model included the following elements:

• Patient knowledge: previsit mailing of comprehensive information

• Flowchart of new process: a detailed diagram of patient flow and provider actions

• Role redesign: changing the role of the registered nurses

Developing the detailed diagram of process flows was a key to success for the first shared medical appointment. The lead improvement team also identified the importance of a detailed plan of education and training to optimize the roles of the RNs. The team also believed that practice makes perfect, so conducting mock shared medical appointments—to simulate the patient and provider flows—was an important part of preparing for the first shared medical appointment.

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