Playbook Clinical Microsystems

Intermediate Cardiac Care Unit (ICCU)

The ICCU lead improvement team maintains a dynamic storyboard for all ICCU staff to review (see Figure 24.2). This storyboard serves as an educational source for staff to communicate progress and as a talking point for leaders and others who visit the ICCU. The conference room walls chronicle the history of ICCU's improvement journey because meeting notes are recorded on flipcharts along with graphics and diagrams.

The data wall continues to grow, blending organizational measures with relevant ICCU data. The data portray real-time progress and help keep the ICCU team alert to progress and trends that might trigger investigation.

The ICCU playbook is under construction. The lead improvement team's initial work resulted in a clear, uniform process for interdisciplinary morning rounds participation with defined roles, defined content for reports, and action items.

Plastic Surgery Section

A visual display of improvement activities and the 5 P's provide constant reminders of the focus and goals of improvement for the Plastic Surgery Section (see Figure 24.3). The data wall keeps staff current on performance and shows when certain processes

FIGURE 24.2. STORYBOARD DISPLAY OF THE ICCU IMPROVEMENT JOURNEY.

Case Study: Intermediate Cardiac Care Unit

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

PURPOSE

The ICCU will create an environment in which cardiac patients and their families can receive excellent, comprehensive, specialized state of the art quality care.

TEAM

lean R.N. Shelly Melanie Edward M.D. Kate lessica Shelby Nancy loanne

Dara

Laurie

Dhaval

Mary

Lucia

Tiffany

Marcia (cardiac patient)

TIMELINE January '06

Attended Coach the Coach (educational session) Established regular team meetings with effective meeting skills Review 5P's February '06

Begin interdisciplinary rounds March '06

Interdisciplinary rounds clarification of roles in rounds

Creation of script for each role

Order of reporting modified

Discharge ticket initiated

April '06

Continued testing of rounding report process Discharge planning ticket revised

Specific Aim Statement

We aim to assign and communicate assigned bed for patients within 30 minutes of request for admission.

Measures

1. Time from phone call to time of admit bed communicated

2. # of admissions/day

3. % of discharges before noon (to open beds for admits) Figure 19.5 Fishbone Diagram: ICCU Bed Assignment*

Physical Environment People

Physical Environment People

Patients

DIAGNOSIS

THEME: Communication Global Aim

We aim to improve the process of communication in our ICCU.

The process begins with the initial notification of the need for patient admission.

The process ends with the appropriate discharge disposition of the patient. By working on this process we expect: Improved patient care and efficiency; improved flow of consistent information between patients, providers and families, improved communication along the health care continuum; a reduction in readmissions; a reduction in stress. It is important to work on this now because we have identified the need to improve: satisfaction of patients, families, and care professionals. We need to eliminate near misses and errors due to poor communication and have clearer plans of care.

*Note. This figure shows the factors that contribute to the delays in bed assignment that prevent achievement of the specific aim: assign and communicate bed assignment for needed admission in 30 minutes

stringing together PDSA cycles, to attain the aim regarding improving the communication process of morning rounds.

NEXT STEPS

1. Continue to test interdisciplinary morning rounds.

2. Prepare scripts and process to move interdisciplinary morning rounds to the bedside to include patients and families.

3. Review and post data on data wall.

4. Review roles and functions to ensure optimized roles.

5. Consider redesign of "care teams" to improve continuity and reliability of patient care.

FIGURE 24.3. PLASTIC SURGERY SECTION DATA WALL.

Ambulatory Clinical Practice Committee

Ambulatory Clinical Practice Committee

Surgery

Plastic Surgery Technical Excellence

Service Excellence

Surgery Plastic Surgery

Cost Excellence: Volume and Efficiency

% Patient Appts with Current Meds and Allergies Verified

| -»Med Charted Allergy Charted |

| -»Med Charted Allergy Charted |

Service Excellence

"1 75

llen 50 el xc 25

02

Patient Satisfaction Rating of Service

Feb 04 Dec 03 Oct 03 Aug 03 |un 03 Apr 03 Feb 03

♦Visit Overall -« Appt Scheduling ♦ Provider Overall

Surgery Plastic Surgery

Cost Excellence: Volume and Efficiency

Number of Follow-up Appts

(Arrived and No Show Patients)

1,000

1,000

Patient Characteristics

Cost Excellence

Service Excellence: Access

Patient Characteristics

Age Distribution of Patients

Receiving Care in Clinic

/

□ 0-10

/ / \

□ 11-24

□ 25-44

□ 45-64

\ ▼

■ 65+

Age Data detected on DP

750,000

J 500,000 o

Income, Expenses and Other Budgeted Costs

Income, Expenses and Other Budgeted Costs

■ Operating Expenses □ Admin Overhead □ Allowances DNet Income

Service Excellence: Access

Associate Hours of Care Delivery

Booked vs Available Appt Slots

15

! 10 H5

^ La a

t

□ Booked Appts (A) ^Available Appts (A)

»■Actual MedSurg Units Budget MedSurg Units

OR Cases

(OR Cases include those assigned to OR Suite Rooms and reported in Or Utilization)

125 100 75 50 25 0

•-Actual OR Cases Budget OR Cases

Top 10 Conditions/Diagnoses

% of All OP Dxs

Other aftercare

32.2

Other skin disorders

9.9

Open wounds of head, neck, and trunk

5.5

Residual codes, unclassified

5.3

Nonmalignant breast conditions

4.7

Other congenital anomalis

4.4

Chronic ulcer of skin

4.3

Other nervous system disorders

3.9

Other and unspecified design necalism

3.6

Other connective tissues disease

3.1

% of All

Referring Provider Distribution

Referrals

ALL OTHER

42.0

INTERNAL-LEBANON

29.3

DOCTOR NOT ENTERED

25.4

INTERNAL-NORTHERN REGIONAL OFFICE

3.3

INTERNAL-SOUTHERN REGION

0.0

INTERNAL-NO LONGER ACTIVE

0.0

DOCTOR NONE/SELF/UNKNOWN

0.0

may need attention to avoid backsliding. The Plastic Surgery playbook continues to grow. Scheduling methods, contingency plans, daily huddles, and shared medical appointments are some of the activities contained in this microsystem's playbook.

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