With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.
Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."
Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.
To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!
To highlight the less efficient aspects of the patient discharge process from a nursing perspective.
To provide a standardized patient discharge protocol for the nursing staff.
To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.
ASPECTS REQUIRING IMPROVEMENT:
Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.
Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.
The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.
At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.
Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:
At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.