Transition of Care Rounds Unit Update: HSP2, HSP3, P9 November 16, 2016

Task Owner (Who is responsible for making sure this gets done) P9 ToC Planning Item Task Name Task Owner (Who is responsible for making sure this gets done) Time Commitment Tools Status Month Start Month End Week of: Duration End Date: 6.0 P9   November December 6.1 Conduct Initial Meeting w/ Service's Medical Staff Leadership, Nurse Manager, Care Transitions Leadership / Staff, Care Transitions Medical Staff Leadership, Necessary Ancillary Leadership Kellie, Michele 1 hr Planning PowerPoints (customizable) Complete October 10/30/2016 7 11/5/2016 6.2 Train ANM / Facilitator ANM Facilitator PowerPoint In Progress 11/14/2016 11/20/2016 6.3 Educate / Planning Session w/ Medical Staff 12/5/2016 12/11/2016 6.4 Train RNs (Shift Report, Scripting) 30 min / session (offered 4 days) RN Education PowerPoint Scheduled 11/27/2016 12/3/2016 6.5 Train CM/SW CM/SW Education PowerPoint 6.6 RN Shift Report Quizzing p9 ANC 1-2 min / RN covered b/t M-F RN Shift Report Training Guide 6.7 CM Milestones Quizzing & EDOD Quizzing 15 min / Day w/ each CM Assigned to Unit Medical Milestones Cheat Sheet & CM Worklist which contains EDOD 6.8 ToC Rounds Week 1 - Quality Review (M-F) - CM - Ensure use of Milestones & EDOD using ELOS - SW - Ensure "since of urgency to discharge" and use of EDOD 30 min Daily (morning) 1 hr Afternoon Huddle Audit Tool Teletracking Care Progression Module 12/4/2016 12/10/2016 6.9 ToC Rounds Week 2 - Quality Review (M-F) - CM - Ensure use of Milestones & EDOD using ELOS - SW - Ensure "since of urgency to discharge" and use of EDOD 12/17/2016 6.10 ToC Rounds Week 3 - Quality Review (M-F) - CM - Ensure use of Milestones & EDOD using ELOS - SW - Ensure "since of urgency to discharge" and use of EDOD 12/18/2016 12/24/2016 6.11 ToC Rounds Week 4 - Quality Review (M-F) - CM - Ensure use of Milestones & EDOD using ELOS - SW - Ensure "since of urgency to discharge" and use of EDOD 12/25/2016 12/31/2016

HSP2:Summary to date As a whole, ToC rounds going well All participants improving; good engagement Sense of increased efficiency with discharges Considering including DVT prophylaxis if time permits Experimenting with order of patient discussion (i.e. Stepdown first vs floor patients) Facilitator effectiveness Assertiveness coaching Trim side conversations with participants part (NM and MD Director to discuss with participants privately) Whiteboard documentation opportunity remains NM trialing ways to hardwire

ToC Rounds Audit Summary Transition of Care Rounds - Audit Summary - HSP2   11/2/16 - 11/10/16 Meeting Length & Logistics Use of Communication Board Start and Length of Meeting Score Goal Communicate to Patients / Family Did the meeting begin / end within 3 minutes of start and end time 40% 100% 5-10 Communication Boards Audited Daily, with focus on: • About Me completed • My Goals / Questions completed • My Transition / discharge plan completed 50% Avg. Meeting Length (mins) 34 Avg. # of Pts 22 Mins / Pt 1.5 Meeting Discussion / Communication Meeting Discussion Summary Overall Score: Average of (2 - 7) 87% 2 Primary Nurse 5 Follow-up Items Stated LOS in days, speaks to plan of care & barriers; progress towards Medical Milestones. Identified, assigned, and communicated follow-up items as they arose; addressed all items from previous day’s meeting 90% 3 Active Facilitation: Facilitator 6 Expected Discharge/Transfer Date Actively led meetings (Kept meeting focused and managed the flow, no lag time with few side conversations or disruptions, Managed participation and elicited missing information, Clarified/restated confusing topics, Reviewed and summarized decisions) Expected Discharge/Transfer Date (EDD/EDT) was discussed for every patient utilizing GMLOS as a barometer 70% 4 Clinical & Logistical Readiness: CM/SW 7 MD / APP Participation Medical milestones and discharge/transition needs were proactively discussed for every patient, demonstrated critical thinking and effective problem solving 80% • Validates/ provides input to plan of care goals and expected discharge date • Identifies issues with plan of care progression and demonstrates problem solving / supportive discussion with team

Measure / Monitor Performance: HSP2 Statistics: <Nov 10 MTD>

HSP3 October ToC Quality Review Transition of Care Rounds - Audit Summary - HSP 3   October Meeting Length & Logistics Use of Communication Board Start and Length of Meeting Score Goal Communicate to Patients / Family Did the meeting begin / end within 3 minutes of start and end time 71% 100% 5-10 Communication Boards Audited Daily, with focus on: • About Me completed • My Goals / Questions completed • My Transition / discharge plan completed 93% Avg. Meeting Length (mins) 31 Avg. # of Pts 25 Mins / Pt 1.2 1.5 Meeting Discussion / Communication Meeting Discussion Summary Overall Score: Average of (2 - 7) 2 Primary Nurse 5 Follow-up Items Stated LOS in days, speaks to plan of care & barriers; progress towards Medical Milestones. Identified, assigned, and communicated follow-up items as they arose; addressed all items from previous day’s meeting 3 Active Facilitation: Facilitator 6 Expected Discharge/Transfer Date Actively led meetings (Kept meeting focused and managed the flow, no lag time with few side conversations or disruptions, Managed participation and elicited missing information, Clarified/restated confusing topics, Reviewed and summarized decisions) Expected Discharge/Transfer Date (EDD/EDT) was discussed for every patient utilizing GMLOS as a barometer 4 Clinical & Logistical Readiness: CM/SW 7 MD / APP Participation Medical milestones and discharge/transition needs were proactively discussed for every patient, demonstrated critical thinking and effective problem solving • Validates/ provides input to plan of care goals and expected discharge date • Identifies issues with plan of care progression and demonstrates problem solving / supportive discussion with team

Measure / Monitor Performance: HSP3 Statistics <Nov 10> September 2015 was selected for comparison because that month had comparable MD to Patient ratios

HSP3 October ToC Quality Review Timeliness – meeting tended to run over on several occasions; one new MD in rounds during this time – has resolved Communication boards – on 10 of 12 audits, marked as consistently complete Constant communication is necessary between ANM and CCRN until patients are actually discharged from the unit is the key MDs and Team are working hard and doing well

Opportunities to Gain Additional Buy-in… Estimated discharge date as a target – presentation at Hospitalist Department meeting (All HSP service)

Continue to monitor and coach Next Steps Continue to monitor and coach Scripting CCRN re: UM questions to MDs & EDD Leadership to observe a weekend ToC Plan and implement P9 Begin discussion with Highlands / collaboration with ACE Pilot Care Progression indicators with Teletracking (HSP3) Celebrate Successes

Appendix

Measure / Monitor Performance Overview Currently Monitoring (McKesson): Average Discharges / Day vs. Baseline % of Discharges Prior to Noon vs Baseline LOS (Sept. data will be available at the end of October) In Development: Average # Delays by Category (Teletracking) Average # of Minutes by Delay by Category (Teletracking) Avoidable Days by Category (CERNER) Employee / Physician Satisfaction

Process Metrics In Progress: Teletracking: Tracking Delays in Progression of Care During ToC Rounds, ANM will electronically document delays impacting care progression via Teletracking Care Progression Module ANMs have been provided a laptop for use during ToC Rounds; this will replace paper log Delays can be viewed real-time by CPF, and will also be reviewed by ANM & Care Coordinators at afternoon huddle Patients with delays will show up on “Big Board” on unit for care team to monitor, and can also be accessed directly by services (e.g. radiology, rehab, etc.) via Teletracking This process will allow for quick escalation of delays to obtain resolution Delays that last more than a day, will be reviewed the next day at ToC Rounds and may be documented as Avoidable Days Teletracking will allow for delays by reason to be trended, along with average length of each delay type. This information can be mapped back to Avoidable Days for monitoring.

Measure / Monitor Performance Reduce Delays > Reduce Avoidable Days > Reduce LOS Reduce LOS / Excess Days 1) ANM logs delays that are preventing Care Plan Milestones or Internal Transfer Milestones from being achieved 2) Monitor delays via “Big Board” on unit, in CPF, and within individual services 3) Escalate delays to appropriate leadership and at ToC Rounds 4) Receive monthly summary of delays by unit On IP side, CMs log Avoidable Days in Cerner based on ToC Rounds UM continues to log Avoidable Days post-discharge As delays are reduce, Avoidable Days should  Receive monthly Avoidable Day Report by Unit and compare to Delays Report As Delays and Avoidable Days are reduce, LOS and Excess Days should  Receive monthly Excess Days and LOS Report by Service and Globally Track / Report thru Teletracking Track / Report thru CERNER Track / Report thru McKesson