QUALITY IMPROVEMENT PROJECTS

Use QI investigation methods to examine:

• The details of your data and identify patient details that may have defined outliers and therefore that may have affected your triggered measure
  • Were the patient circumstances out of your team’s control? Perhaps the trigger can be dismissed with clinical expertise?
  • Were the patient circumstances within your team’s control? What can your team do differently next time to achieve the desired results?
• Your local work flows and identify possible points affecting the team’s ability to coordinate appropriate care

Notes

Length of Stay (LOS) measures the duration of a single episode of hospitalization. The average LOS provides a good benchmark for efficient care. A multidisciplinary team is important to coordinate appropriate discharge. The provincial goal is to reduce LOS, so if your team sees your site’s LOS increasing you may get a notification on your trigger report.

Try This

• Use the General Try This at the top of the web page
• Revisit the Same Day Discharge package for guidance on delivering a short arthroplasty program
• Hold discussions with all disciplines, including your local H&K Clinic, to brainstorm ideas to deliver cohesive messaging to patients. Fully cohesive communication to patients is known to be important to reinforce patient perception of discharge expectations.

Examples of QI projects that are currently in place to help reduce LOS

• Quiet at Night (Royal Alexandra Hospital): Team works closely with the Elder Friendly Care team to increase awareness and improve sleep patterns on unit. The outcomes are based on readmission rates, length of stay and patient feedback.
• H&K KPI & Scorecard Check-in (Chinook Regional Hospital): Goal is to improve the length of time between decision for discharge and discharge from unit. The project involves better rounding of the orthopedics team to complete all discharge instructions and have the patient discharged off unit within 2 hours after decision to discharge.

Notes

Infection is monitored and regulated by Infection Prevention and Control (IPC) Alberta and the reported measure includes both in-hospital and post-discharge infection. Contracting infection can increase LOS, transfusion rates as well as readmission rates.

Try This

• Use the General Try This at the top of the web page
• It is important to present findings to orthopaedic surgeons who are the leaders in the Operating Room (OR) where infection is most likely to be contracted. Hold a discussion about compliance with the care path and invite brainstorming about opportunities to adjust practices.
• Review Alberta Heath Services’ (AHS’) Surgical Site Infection (SSI) protocols for Hip and Knee Arthroplasty https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-sr-hip-knee-ssi-protocol.pdf with the entire operating team to see if there are opportunities to tighten both operating and cleaning practices.
• Review your local bandaging protocols. Hold a discussion with nursing teams on the inpatient or day surgery ward to explore any opportunities to adjust bandaging practices.
• Contact your local IPC representative (and if you do not know your local rep try the generic contact IPC information: https://www.albertahealthservices.ca/ipc/Page6425.aspx#contact) to collaborate on investigation of infection incidents, review of practices, and creation of solutions.

Notes

In hospital medical events are a rare occurrence in H&K. The most common of these events are pulmonary embolism (PE) and deep vein thrombosis (DVT). This measure is a combination of multiple different events so you may need to investigate further which particular event caused this measure to rise. Mobilization POD1 is important to reduce rates of DVT.

Try This

• Use the General Try This at the top of the web page
• Review your mobilization rates and hold a discussion with the entire team on the inpatient ward or the day surgery ward about practices for mobilization. Is it the nursing or allied health staff who are taking a lead with this task? Are the numbers being recorded properly?

Notes

Discharge location is heavily weighted around planning appropriate discharge for the patient. Discharge planning is a process used to decide what a patient needs for a smooth move from one level of care to another. The multidisciplinary team plays an important role in discharge planning by evaluating and determining the patients at home situation, then arranging for appropriate support. Effective planning can also decrease readmission rates.

Try This

• Review workflow for triggering social work both with your local clinic and with your hospital team. Are social work services appropriately available for the patients who require it?
• Brainstorm with your local clinic: is the requirement of a buddy still being fully enforced by the clinic staff? If not, what could be changing in your patient population that makes it difficult to identify and engage buddies?
• There have been some changes to home equipment sourcing across the province over the last few years. Do you and your clinic still have good vendors to direct the patients to, in order to get them appropriate set up for home discharge?

Notes

It is important to track, reduce and prevent surgical site infections, as it can increase readmission rates (and cause longer LOS). A well communicated discharge education program is crucial, some sites have developed a video that can play in the patient’s room, others offer teaching in groups so patients can discuss what they learned the information is provided. The Nursing Discharge Instructions form has been provincially standardized and should be used by all sites to handout to patients upon departure. Following discharge, all relevant patient information should be communicated back to the case manager at the clinic in a timely manner. The case managers at the clinic can provide a check-in call with the patient to provide support with post-op care and to discuss complications the patient may be having.

This measure is a good opposite measure to LOS and can indicate if a short LOS is not truly effective.

Try This

• Reviewing which Emergency Departments your triggered patients presented at and why they presented there. We know that rural patients have longer to travel and do not always return to their H&K Clinic for staple removal.
  • If the patient’s visit should really be coded as routine staple removal ABJHI can help to communicate to leadership that the trigger has been explained.
• Otherwise, consider:
  • Calling some of your patients to get ideas about how discharge education can improve.
  • Connecting with your clinic to understand their success rate with the check-in calls after discharge, and to gather any feedback they are receiving about the clarity of patients’ understanding of the supports available to them.
  • Brainstorming with your team to identify opportunities for refreshing content or redesigning delivery of the discharge education.

Notes

This measure is very similar to Emergency Department Visits within 30 days. As above: monitor surgical site infections, provide strong discharge education, use the Nursing Discharge Instructions form, and coordinate with clinic case managers to provide post-op check-in calls.

This measure is also a good opposite measure to LOS as it can also indicate if a short LOS is not truly effective.

Try This

• Reviewing which hospital sites your triggered patients presented at and why they presented there. We know that rural patients have longer to travel and do not always return to their H&K Clinic for staple removal.
  • If the patient’s visit should really be coded as routine staple removal ABJHI can help to communicate to leadership that the trigger has been explained.
• Otherwise, consider:
  • Calling some of your patients to get ideas about how discharge education can improve.
  • Connecting with your clinic to understand their success rate with the check-in calls after discharge, and to gather any feedback they are receiving about the clarity of patients’ understanding of the supports available to them.
  • Brainstorming with your team to identify opportunities for refreshing content or redesigning delivery of the discharge education.