Improving Teamwork with Multi-Disciplinary Rounds
“Improving Teamwork with Multidisciplinary Rounds”
Project Aim: The aim of this expedition, Improving Teamwork with Multidisciplinary Rounds, is to help teams ensure that the most appropriate people participate, communicate and collaborate in rounds with the ultimate goal of improving outcome through teamwork with a focus on Patient Safety.
Time Frame: September 30, 2010 to present
Involved: Core Team: Darren Childs, VP, Quality Improvement; Baxter Holland, MD, Medical Director; Daniel Foley, MD, Chief of Obstetrics and Gynecology; Karen Cartier, Risk Manager; Dorie Ward, CNO; Kathy LaMontagne, RN, Director Intensive Care Unit; Denise Simpson, Director of Performance Improvement (PI); expanded in January 2011 to include Nancy Meszaros, RN, Infection Prevention/PI Specialist; Alexandra Foley-Bowen, RN, PI Specialist; Thomas Hartigan; and the corresponding Nurse Director for each unit implementing rounding.
Background: The project was conducted in conjunction with the Institute for Healthcare Improvement (IHI), initiative. Multidisciplinary rounds have been shown to improve patient outcomes, reduce errors, reduce length of stay, reduce costs and improve communication, collaboration and satisfaction among all members of the multidisciplinary team.
Description: The project was initially trialed on the Intensive Care Unit and the Women and Children’s Unit.
The focus in the Intensive Care unit was on Ventilator Associated Pneumonia Care and prevention. The team on this unit consisted of the Infection Prevention RN/Performance Improvement Clinical Specialist, the staff RN, the unit Nurse Director and the Respiratory Therapist.
The focus on the Women and Children’s Unit was the post operative obstetrical and gynecological patients. The team on this unit consisted of the attending physician, the staff RN, the unit Nurse Director, the Social Worker, the unit’s Nurse Educator, and the Performance Improvement Clinical Specialist.
The multidisciplinary rounding process was then replicated on the Fifth Floor Medical Oncology Unit with a focus on patient falls and pressure ulcers. The team on this unit consisted of the staff RN, the staff LNA, the WOC Nurse, the Performance improvement clinical specialist with assistance from the RN Clinical Manager and unit Nurse Director.
The rounds were tailored to the special needs of each unit and included specific targets/goals such as validating bundle compliance in ICU, and assessing social needs and opportunities for early interventions for post operative women. For the Fifth Floor Medical Oncology Unit, the nursing aids enhanced communication and were empowered to advocate for patient safety.
Process Measures: Number of days rounds occurred, number of patients that were rounded on, number of days with at least two team members present, number of days with recommendations from the team.
Fifth Floor Medical Oncology Unit: Decreased number of Unit Acquired Pressure Ulcers and Decreased Number of Patient Falls
On the Fifth Floor Medical Oncology Unit rounds project:
There were 36 possible days patients could have been rounded on. Of these days, 97% of the days rounding occurred. Of patients rounded on, safety recommendations were made by the team 97% of the time. Examples of recommendations include enhanced communication within the care team by standardizing the use of the white board, providing education regarding skin care barrier products indications and implementing toileting, walking or repositioning schedules.
Conclusions: The project originated based upon the IHI series, “Improving Teamwork with Multidisciplinary Rounds”. Over the course of two years our teams evolved over three units with unique needs and goals. With each expansion, the process of rounding with multidisciplinary participants focused on identifying and addressing patient safety needs as a common thread. The success was captured by process measures during this phase. Outcome measures are more difficult to associate due to small volumes, but are presented. Qualitative measures of satisfactions are evident. Quotes below are from the Fifth Floor Medical Oncology Unit staff:
“Rounds remind staff members the importance of using the white boards to communicate about each individual patient.”-Medical Oncology Unit Staff Member
“I feel more connected to the people I am working with.”
- Medical Oncology Unit Staff Member LNA
“I second that, I do feel more connected with the people I work with, with ongoing communication and reminders of the things that are most important regarding the safety of our patients.”
- Medical Oncology Unit Staff Member
Our experience has led to a better understanding of the value of rounding. We will include our learning as we go forward with patient rounds.
Vice President of Quality Improvement
Director of Performance Improvement
Congestive Heart Failure (CHF) Readmissions Reduction
Congestive Heart Failure (CHF) Readmissions Reduction
Timeframe: June 2011-Present
Description: Hospital readmission rates are under close scrutiny by payers and policymakers including the federal government because of the high costs involved (and therefore high potential for savings). In addition to the costs, patient readmission rates are increasingly being used to measure quality of care, are being publicly reported, and soon will be directly tied to some of the financial programs being put into place as part of national healthcare reform. Many patient readmissions to hospitals represent good care such as those that are part of a course of treatment planned in advance by the patient and their physician, or those that are done in response to trauma or a sudden acute illness unrelated to the patient’s original hospital admission. However, sometimes hospital readmissions are avoidable and that is the focus of this Team: to find ways to reduce avoidable hospital readmissions for patients with congestive heart failure for a minimum of 30 days after their hospital stay.
Background: In 2011, the Vermont Association of Hospitals & Health Systems (VAHHS) asked all Vermont hospitals to come together and work on a common goal; to collaborate as one group to share ideas, successes, and best practices so that all organizations and our patients could benefit from each other’s experience. The topic chosen was to reduce avoidable 30-day readmission rates for patients with congestive heart failure (CHF). CHF is a long-term (chronic) condition in which the heart can no longer pump enough oxygen-rich blood out to the rest of the body, especially when the patient exercises or is active. It may affect on the right side or only the left side of the heart, but more often both sides of the heart are involved. As the heart’s ability to pump blood is lost, the blood may back up in other areas of the body and fluid builds up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is congestive heart failure.
Most Vermont hospitals, including Rutland Regional Medical Center (RRMC), agreed to participate in the state-wide collaborative. As RRMC began to analyze its 30-day readmissions for CHF patients, currently averaging between 20-24%, we quickly realized that we needed to involve other more regional organizations and physicians in our improvement efforts. We invited the three local skilled nursing facilities, two home health agencies, Cardiologists, primary care physicians, office coordinators, and others to partner with RRMC to improve the care coordination amongst all of our organizations for the benefit of our patients. These other organizations agreed to participate and we have been working together as a collaborative with the shared goal of reducing avoidable admissions for these patients. Our analysis of our CHF patients being readmitted, along with a literature search and best practice ideas sharing from other organizations working on CHF, led us to the establish of the project goals- the areas where we felt we could make the biggest impact to help our patients.
1. Complete analysis of all CHF patient 30-day readmissions from 2009-2011 to identify opportunities for improvement to reduce avoidable admissions.
2. To collaborate with other area health care providers and facilities to develop communication processes that cross organizational boundaries for the benefit of improving patient care and coordination.
3. To implement evidence based best practices when evaluated as appropriate for our hospital, community and patient population.
4. Overall measure to be used to gauge success on the project: Medicare 30-day all cause readmission rate. Current monthly rate averages in the 20-24% range.
1. Jointly develop standardized clinical protocol for managing CHF patients in the community setting and determining the clinical criteria to be used for sending a patient to the hospital.
2. Improve the coordination and communication between the hospital, skilled nursing facilities, home health agencies, and physician practices so that when patients are admitted and then discharged from the hospital to another organization, we improve the ‘transitions of care’.
3. Evaluate the potential for more patients to receive Home Health if they are eligible and would benefit from those services.
4. Develop a standard of the clinical terms and advice given to patients as they are treated and cared for by/at the different facilities participating in this CHF collaborative. Develop a standard, effective patient journal to empower and encourage the patients to better self-manage.
5. Provide a follow up telephone call to each CHF patient within 1-3 days after hospital discharge. This will be done to help answer any questions the patient may have, and to help ensure the patient understands and follows their discharge plans including getting prescriptions filled, dietary & other behavioral modifications, regular weight checks, follow up appointments with their physician and similar activities.
6. Ensure the patient has a good understanding and an accurate list of the medications that he/she is taking. This list is also shared with others caring for the patients to ensure medication safety.
7. For those patients with advanced stages of CHF, it may be beneficial to have palliative care discussion and advice with a nurse or patient’s doctor so that the patient’s wishes and best interests are known and factored into the care decision making practices.
Evaluation process: A subgroup will be formed to coordinate, plan and implement each of the interventions listed above. Each subgroup will be responsible for the evaluation of their intervention. At this time, each team is still working on their interventions and some are in the early stages of implementation. A formal evaluation of the end result is planned for the near future.
Contact for project: Darren Childs, Vice President of Quality Improvement, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone 802.747.3704.
Physician Leadership Development
Physician Leadership Development
Time Frame: October 2011 - ongoing
Background: Physicians often find themselves in positions of leadership – within their practices their health systems, their communities, and the larger health arena. While medical school has prepared them to successfully overcome a wide variety of clinical challenges, it is unlikely to have supplied the basic principles and practices of effective leadership.
In 2011, Rutland Regional established a physician leadership development initiative to address this need.
Healthcare is in a period of rapid change at the national, state and local level. In light of these changes, Rutland Regional has made and will continue to make structural changes which require strong physician leaders partnered with administrative leaders. Many of those changes reflect a deliberate move toward a more integrated health care delivery model. Additionally, the number of physicians with formal leadership roles within the organization has grown and will continue to grow as more physicians become employed. The aspiration of this project is to produce a cadre of physician leaders who work individually and together to effectively advance health and health care at Rutland Regional.
1. Describe the skills and attributes of a successful physician leader.
2. Design a process to equip physicians with the knowledge and skills necessary to become effective leaders.
3. Promote physician and administrative leader partnerships.
4. Move toward an integrated care delivery model.
The purpose of the project is to design a process which will equip physician leaders with the knowledge and skills necessary to become effective leaders. It is anticipated that a successful physician leadership development process will foster interest among potential physician leaders, support and strengthen the dyad model of leadership (physicians and administrative leaders) and build confidence within our community in our ability to provide excellent service.
Our methodology for this project is based on the Plan-Do-Check-Act method and is specifically designed to guide the development of new processes. We call this method DREAM – Design/Redesign Effectiveness Assurance Method and it includes the following steps:
1. Define Requirements
2. Feasibility Check
3. Initial Design Proposal
4. Final Design
5. Plan and Test the Design
6. Check Results
7. Fully Deploy
8. Plan for Continuous Improvement
1. Conducted focus groups with current and potential physician leaders to establish necessary skills of effective physician leaders and identify preferred methods of learning.
2. Invited two prominent local physician leaders to provide experiential knowledge and elicit discussion and engagement with our physician focus group.
3. Conducted research of physician leadership development models.
4. Drafted a curriculum combining Rutland Regional specific and ACPE (American College of Physician Executives) courses to support both the dyad model and broad physician leader knowledge.
5. Drafted a business plan.
Anticipated measures of success will include knowledge assessments course evaluations.
At this point in our project, we have engaged current and potential physician leaders in the design of an effective physician leadership development process. This project will be piloted in September, 2012.
Denise Simpson, MS, CIC, CPHQ
Director of Performance Improvement
Director of Learning and Organizational Development