Best Practices: Taylor VHA RAN Team Strives to Improve Discharge Process, Reduce Readmission Rates
In 2009, a team from Taylor Hospital began work on a VHA Rapid Adoption Network (RAN) project focused on improving the discharge process with the ultimate goal of promoting patient safety and reducing re-hospitalization rates. A related goal is to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to two discharge instruction questions:
(1) Did the staff talk to you about help you might need at home after your hospital stay?
(2) Did the staff give you information regarding symptoms and problems to look for?
VHA RAN team co-leaders Alisha Hartunian, RN, BSN, clinical director of Taylor Hospital’s Intensive Care Unit, and Mary O’Prey, RN, BSN, clinical director of Taylor’s 2 West Medical-Surgical and Orthopedics Unit, began tackling the challenge at the VHA Clinical Design Day held in October 2009. They discussed Taylor’s current discharge process, learned methods for observing and identifying opportunities for improvement, and discussed best practices that have enabled VHA hospitals to dramatically improve their HCAHPS scores.
“The discharge process should begin at the moment a patient is admitted to the hospital and continue through the end of the patient’s stay,” says Hartunian. “The patient should be continuously educated about new medications and treatments prescribed, as well as warning signs and symptoms to look for once they leave the hospital. When this is done consistently, patients better understand what they need to do when they go home, which results in fewer readmissions.”
Mary O'Prey, RN,
Following the VHA meeting, Hartunian and O’Prey conducted user observations at Taylor using the VHA’s contextual model. “We went out on the units to observe what goes on in relation to the discharge process,” explains O’Prey. “This contextual approach gave us the opportunity to see firsthand what was being done well and what could be changed to maximize value to the patients and their families, as well as the staff.”
The two observed weekly discharge rounds attended by a primary care nurse, social worker, case manager and pharmacy representative. “It was clear that the rounds were not as efficient or effective as they should be,” says Hartunian. “Nurses were away from their patients for a long time. Not all members were attending, and no physician was involved. Afterward, information regarding discharge plans often was not relayed to the patient.”
The team leaders also observed the way information and instructions were conveyed from nurse to patient at time of discharge. They noted that the environment was noisy with bells and pagers constantly ringing. Some medication prescriptions were missing and the discharge documents were difficult to read and incomplete. The nurse was interrupted several times while talking to the patient. Moreover, the nurses often had to review instructions twice – once with the patient and once with the family.
When Hartunian and O’Prey looked at patient records and multidisciplinary documentation, they discovered that each care provider (i.e. physician, nurse, physical/occupational therapists) was not necessarily aware of what the others were doing. Additionally, the care team did not have a good sense of when the patient could be discharged since the plan of care was not documented daily.
Hartunian and O’Prey established a multi-disciplinary team to develop recommendations for improving the discharge process. The team based their work on Project RED (Re-Engineered Discharge), a highly successful discharge model established at Boston University Medical Center and supported by grants from the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH)-National Heart, Lung and Blood Institute (NHBLI).
Taylor’s VHA RAN team has launched pilot programs for the following process changes.
- The tentative discharge date is documented on the patient record every day by the attending physician. An attention-grabbing neon green form is placed in the patient’s record daily for this purpose. If the tentative discharge date changes from day to day, the form includes a place to document the reasons for the change.
- The team piloted the new form on Taylor’s Telemetry Unit with a group of hospitalists and cardiologists. During the pilot, there was 68 percent compliance with use of the new form. The team expects to increase compliance over time and eventually eliminate the separate green form, making this documentation part of the progress notes that the physician completes every day.
- The green form also serves as a signal to bedside nurses to document the tentative discharge date on the white board in the patient’s room. This enables the patient’s family to be better prepared when it is time to take the patient home. During the pilot, nursing adoption of discharge date documentation on the white board was limited. After tweaking the process, the team launched a second pilot on Taylor’s 2 West Unit in April 2010. A “Tentative Discharge Date” magnet has been placed on the white board in each patient room as a reminder to nurses to document.
- The discharge record is being revised to make the documents more patient friendly and easier to understand. One patient-friendly feature that has been added to the medication form is a set of pictures to indicate the time of day that each medication should be taken -- morning, noon, evening and bedtime. Check boxes have been added to make instructions such as “by mouth” more clear, replacing medical abbreviations such as “PO.” The new discharge medication form is set to be piloted on 2 West.
- The “Discharge Folder” given to each patient on admission is being revised and updated to include information that is more relevant and valuable for educating the patient in preparation for discharge. It will include the patient’s test results and complete discharge record. A sticker with the discharge date will be placed on the front of the folder, making it easier for patients to reference information about a specific hospitalization after they are home. The new folder will be distributed in May.
Other initiatives include educating staff about the importance of ongoing patient education in a quiet, uninterrupted environment with a “teach back,” Hartunian says. “Once the nurse reviews the discharge instructions, the patient is asked to repeat them back to be sure he or she understands.” The team also conducts weekly literature searches for discharge best practices.
The team is measuring success through random chart audits and by monitoring HCAHPS scores against performance improvement goals set by Crozer-Keystone.
Taylor VHA Rapid Adoption Network Team – Discharge Process
- Alisha Hartunian, RN, BSN, co-leader
- Mary O’Prey, RN, BSN, co-leader
- Nadeem Anis, M.D.
- Eileen Garrity, RN, MBA, FAHM
- Howard Gitter, M.D.
- Barbara Alexis Looby, MSWAC, LSW
- Darlene Luther, RN
- Marion Severson, RN, BSN