Serving Wyoming’s entire Big Horn Basin, Cody Regional Hospital made it simple for patients to travel the short distance from acute care to long-term care. But by late 2014, transfers were being delayed and denied.
Cody Regional’s state-of-the-art, 25-bed, acute care facility is connected to a 94-bed long term care center (LTCC). Staff members in acute care and long-term care excel at caring for patients in their individual areas. However, outside of those departments, clinicians were unfamiliar with the decision making and process steps needed to facilitate patient transfers. This was resulting in unnecessary delays and bottlenecks. For instance, the acute care team might deem patients ready for long-term care, but the LTCC staff might not be ready to admit a new patient. In this case, patients would have to stay longer in acute care (avoidable days) or be transferred outside of the Cody Regional facility. Both of these outcomes were undesirable. If they could not be accepted by the local LTCC, family members would be forced to drive long distances to visit loved ones. In addition, this resulted in lost revenue for the hospital, since patients could not be placed in the local LTCC. Senior leaders and staff members knew they needed to meet the needs of the community and still maintain high quality care. It was time for a change.
“The staff had a long record of patient-focused care for current patients, which occasionally conflicted with timely throughput for new patients. The two departments had shared goals but needed a shared approach to address the full continuum of care,” explained QHR’s Quality, Safety & Performance Improvement.
West Park’s CEO knew he could trust those staff members closest to the process to resolve this constraint and knew that Lean education would help staff members gain problem solving skills. Groups of senior leaders, physicians, managers, front-line staff and offsite clinic staff were trained to use Lean principles for process improvement. QHR provided organization-wide education to all departments to help address workflow issues over the coming years.
Restructured Quality Improvement Committee
Early in the Lean journey a team of physician leaders and senior leaders was established to ensure the organization’s strategic objectives were addressed in the future. This steering team was created through the streamlining of existing committees to allow the multidisciplinary group to meet monthly. Increasing physician leadership on the Quality Improvement Committee ensured greater collaboration and effective prioritization of quality issues.
Rapid Improvement Event
QHR consultants facilitated a multi-day rapid improvement event, embedded in a seven-week cycle of change, guiding hospital and LTCC staff to develop the highest quality, patient-centered process to transfer patients to the hospital’s LTCC. Front-line staffs, managers and leaders were all involved in the study, problem solving and transformation, beginning with a deep understanding of patient needs, mapping the entire process, addressing barriers and devising metrics for success. Finally, new processes were tested, monitored and honed according to collected data and staff feedback.
As a direct result of QHR’s Lean process improvement solution, wasteful, ambiguous and ineffective process steps were removed from the workflow, creating extra space for patient-centered activities. The team inserted a daily LTCC planning discussion within the existing daily acute care planning meeting, which enabled immediate decision-making about transfers. Work procedures were re-sequenced, status boards were more visually intuitive and accessible, standard communication protocols were drafted to clarify patient wishes and set expectations before transfer. In addition, cross training began in areas of need and the team developed tools to better support access to information, when and where it was needed.
Some staff did not adapt as quickly to the tests of change. The improvement team responded by listening to these staff concerns and focusing on additional communication about benefits to the patient, an openness to short term testing and reliance on evidence to guide final decisions. In the end, the process proved itself and made critics into converts.
Since the new processes have been implemented, all late day, same day and weekend transfer requests were completed in a timely manner and admission delays have been virtually eliminated.
Perhaps most significantly, internal referral denials, which were sometimes as high as six per month, were also eliminated. Avoidable hospital days decreased and have continued to decline. And staff productivity and efficiency as well as bed availability rose. Most importantly, patient satisfaction remains high and more patients are able to receive care in their community.