Length of Stay Reduction Project – UMMCH Unit 6 MMRB presentation 9-13-18

Disclosure Funding: internal only

Quality gaps we aimed to address Reducing Length of stay (LOS) has impact on reducing healthcare costs, especially for those on Observational Status = ↓COST Reducing LOS can significantly impact throughput and hence patient access to hospital resources = ↑ Quality & Safety Often cited concern in reducing LOS is that it may result in increased readmissions.

Factors Impacting DC Timing Attending/team rounding Completion of DC orders Pharmacy Rx dispensing and education Interpreter services Scheduling home health services, meds, equipment Nursing education Patient education – learning center Flu shot Family ride

Primary AIM: Decrease the average LOS (ALOS) of our Peds patients on Units 6 from baseline 5.8 days to 5.3 days within 2018. Measures: ALOS averaged over last 12 months (outcome) Mean discharge time before 11 am (process) Interval from DC order time stamp to actual patient departure (process) No increase in readmissions (balance)

LOS Project Interventions: Phase 1 focused exclusively on Peds Hospitalist pts “Discharge Care Coordination Huddle” Mon-Fri from 8:45-9am Intervention 2: “Discharge rounds” – purposefully round on planned/likely patient DCs from 9-10am Round & sign orders to DC home Avoid scheduling routine things (such as Interpreters) for non-DC patients during this time Intervention 3: “Tuck-in rounds” – Daily from 2-4pm, Team to run list or revisit patients with focus on: Who is potential DC for next day? Have DC meds been reconciled? Is family aware of potential morning DC regarding ride planning? If flu season, has flu shot been reconciled? See next slide for more details Intervention #1 implementation: Jan 21, 2018 Interventions 2&3 simultaneous implementation: May 8, 2018 May 2018

LOS REDUCTION PROJECT PHASE I was initiated with Gen Peds Hospitalist teams on 1/21/18

Outcomes:

Project Outcomes: Unit 6 LTM ALOS goal of 5.3 days was achieved for Unit 6!!! Last 12-month (“LTM”) data

Project Outcomes: Unit 5 LTM ALOS on Unit 5 has increased over study period, but Peds Hospitalists manage a small # of Unit 5 patients, so future PDSA cycles with other specialty groups will have more impact there. Last 12-month (“LTM”) data

Process Metric: Distribution of Discharges by Time of Day All of 2017 1/21/18 – 9/4/18 The peak on the baseline at 2pm has shifted & leveled out, with more of the discharges happening earlier in the day

Process Metric: Discharge Order to Pt Discharge Time Lag, Unit 6 Goal: The time from Discharge order written to actual discharge is 60 minutes or less 80% of the time. Intervention cycle began March 21, 2018 to current N Mean StDev Baseline Time From DC order 1588 135 126 After Time From DC order 732 140 153 Estimate for difference: 3.45 P-Value = 0.468 (Last month 0.366) = no significant difference Unit 6 Order to Discharge Baseline After P Value 60 Minutes or Less 25% 27% same as last month .289 120 Minutes or Less 54% 57% same as month .211

Balance Metric: Unit 6 Readmissions (Jan 2016 - May 2018) Intv’n #1 Intv’n #2 This represents random variation. From Jan-May 2018 (our study period) no significant changes were noted, compared to pre-intervention Jan 2016-Dec 2017.

Spread/sustain strategies Project is ongoing Working with nurses on a few interventions to impact DC order to actual DC time lag Will be spreading these 3 interventions to other Pediatrics attending services shortly: Pulm/Cards (already started), GI & Nephrology Dissemination plans via internal communications or publications are still under discussion