Team #4 Will Farmer, Anna Munaco, Esha Sondhi, Maggie Steele University of Michigan Comprehensive Stroke Center Improving the Discharge and Post-Discharge Process Flow Final Report April 11, 2017 Team #4 Will Farmer, Anna Munaco, Esha Sondhi, Maggie Steele 1

Introduction Client Jenevra Foley, Operating Director of Stroke Clinic Coordinators Kevin DeHority, MQS Lean Coach Andrea Case, Administrative Fellow 1

Background Follow-up 7-day call from Stroke Coordinator Home with Outpatient Rehab Follow-up 7-day call from Stroke Coordinator Follow-Up Appointment Patient deemed ready for discharge Discharge disposition identified Inpatient Rehab Facility 1

Project Scope Ischemic Stroke Patients Discharged to Inpatient Rehabilitation Facility (6A) Discharged to home with outpatient rehabilitation 1

Goals and Objectives Primary Goal Improve the discharge process of stroke patients at the Comprehensive Stroke Clinic by streamlining the steps involved in the discharge and follow-up processes Create current state workflow Analyze and identify barriers and waste Provide an A3 picture story Provide a summary of improvement opportunities 1

Expected Impact Enable Future Process Monitoring Improved Data Collection Process Expected Impact Less Rework Improved Communication 1

Methods Literature Search Interviews and Observations Historical Data Analysis Flow Chart A3 Report and A3 Picture Story 1

Findings 1

Future State of this Project Literature Search Future State of this Project Six Sigma Analysis 1

Insufficient Data Require sample size of 377 for 95% CI 5% Error Unable to find correlations between attributes and issues 2

Lack of Standard Workflows Notification of IRF Bed Required Notification of IRF Bed Availability Search for Outside Beds Post-Screening Social Work Involvement Timing of Medical Insurance Clearance 2 “Talk about handoffs”

Unresolved Issues at 7-day Phone Call 2 15.2% of all calls are “Normal”

Unresolved Appointment Issues 2

Unresolved Issues at 7-day Phone Call Appointments Nursing Advice Consultations Stroke Nurse Case Managment Neurosurgery Medication Bridge NP, PA Social Work Reschedule Smoking Insomnia Physician New PCP Unresolved issues discovered at 7 day phone call Opthy Fatigue ACT Therapies Unable to Reach Referrals Called more than once 2

Key Staff Roles Have No Cross-Coverage Resident Assistant Schedules patient follow-up appointments Manages ACT monitor equipment order and placement IRF Admissions Coordinator Monitors and updates patient admission list Rearranges patient rooms to maximize capacity Manages sending a patient to outside facilities 2

Handoffs Leading to Confusion To IRF To Home 4A Physician 4A Nursing IRF Administration IRF Consult Team OT/PT 4A Physician 4A Nursing 4A Care Manager 4A Administration 4A Stroke Coordinator OT/PT Insufficient understanding of other’s roles Lack of standard work responsibilities No use of checklists 3

Gaps in Continuity of Patient Care Lack of timely and accessible stroke education resources Patients left without adequate access to education resources Confusion over patient ownership between discharge and follow-up Lack of triage algorithm for patient questions and concerns 3 “This binder should stay with you” “These are the people you can call”

Communication Gaps and Transparency Stroke Rounds Underutilization of MiChart 3

Baseline Discharge Data Findings Critical Time Metric Variability assessment Mean assessment Writing a Discharge Note In Control Not Meeting Target Discharge Order to Discharge In Control Not Meeting Target Discharge to Follow Up In Control Not Meeting Target 3

IRF Admissions Data Findings Critical Time Metric Variability assessment Mean assessment Discharge Order to Discharge In Control Not Meeting Target Consult to Admit In Control Not Meeting Target Medical Clear to Admit In Control On Target 3

Recommendations

Collect Additional Data Metric Problem Owner Follow up phone call date Insufficient Sample Size Stroke Center Follow up phone call issues Readmittance to IRF Date Insurance Clearing Time Unmeasured Metric IRF Admissions Time on IRF Admissions List Time to Outside Facility 4 sample size vs lack of data

Communicate Roles and Responsibilities Reduce tension and lack of understanding between roles Show the need for standardization and communication 4

Make Resources More Robust and Accessible Add Education Resources to Patient Portal Assign Heartcare learning modules Emphasize importance of binder to patients and caregivers 4

Delineate Patient Ownership during Follow-up Process Patient is discharged from Unit 4A/4AS to home Patient attends follow-up appointment Develop triage algorithm and response time goals 4. Clear guide for stroke center call center

Cross-train Staff on Key Roles Resident Assistant IRF Admissions Coordinator 4

Update Discharge Dates Daily Incorporate Standardized Communication Between Unit 4A and IRF Consult Team Additional Huddles Update Discharge Dates Daily 4

Team #4 Will Farmer Anna Munaco Esha Sondhi Maggie Steele Thank you! Questions? Team #4 Will Farmer Anna Munaco Esha Sondhi Maggie Steele