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Karen Meredith thought she had a pretty good idea on how to reduce discharge delays when she enrolled in the Lean Leader Level One – Applied Problem Solving course in May 2015.
"It was obvious to me that the transfer of accountability (TOA) form was too long," says Karen, Patient Care Coordinator, Intensive Care Unit, Toronto Western Hospital. "But when I dug into the situation, I got to the root cause of the problem – and it was something I never suspected."
And the problem is one well worth solving. Although only 20 per cent of delays longer than 30 minutes are within a unit's sphere of influence, these delays can result in more than 78 days of lost patient care time every year. This includes time lost for staff waiting on the unit to receive patients, and subsequent delays in sending patients to the ICU.
During the problem solving course, which is offered by the Lean process improvement department, Karen learned how to collect and analyze data, brainstorm potential causes and verify the root cause of a problem.
Lean is how UHN pursues continuous improvement. It is a long-term method for making small, incremental changes in processes to improve safety, quality, delivery and efficiency of the organization's operations.
With the support of Kim Partridge, ICU Manager, Toronto Western Hospital, Karen worked with her problem solving team to develop a two-page questionnaire for nurses to complete when they transferred a patient. Although it took some time to fill out, she says it provided useful information for narrowing down potential causes of discharge delays such as waiting for test results or paperwork not started.
"From that first round of data collection, where we interviewed nurses and watched as they discharged patients, we realized we were on the wrong track with the TOA form," says Karen. "We began to see that the real problem was in how we balanced our workload."
The ICU unit cares for Level 2 patients and Level 3 patients, which require round the clock observation and care. The nursing ratio for Level 2 patients is one nurse and two patients, while Level 3 patients are a one-to-one ratio.
Karen's team discovered that although the L2 patients are less acute than L3 patients, they often require more care from their nurses, especially if they are due to be discharged, or have a CAT scan or an MRI.
This means some nurses have to complete paperwork for two patients in one day, while another colleague may have only one patient and much less paperwork. Completing TOA forms for two patients, if both were transferring at the same time, can cause delays when only one nurse is assigned to the task.
Discharge delays cut by nearly half
The unit cut average discharge delays in half almost immediately by changing the way they allocate nurses to patients. However, Karen's team is still trying to improve the TOA form by eliminating redundancies and duplication.
Now, the team looks at the patient's care plan the same day nurses receive their assignments for the day. L2 patients with high care requirements are no longer assigned to the same nurse.
Daily huddles are also completed so the nursing team can assist one another if a colleague feels overwhelmed.
"I'm so thrilled with Karen's work," says Kim.
"This problem wasn't an easy one to solve but it was worth doing. We can potentially reclaim almost 40 days of patient care time, and spreading out the paperwork will result in a higher level of care for all our patients."
Click here for more details on all eight steps of Karen's problem solving journey.