Integrating HSD Principles to Promote and Sustain Best Practices Regionally in Care and Discharge Planning

As leaders and practitioners, we regularly work within the boundaries of fiscal and time constraints. These, layered with the increasing demands and complexity in the system result in frustration, burnout and less-than-optimal patient care.

Fraser Health hosted a series of region-wide summits to explore how to deal with these constraints. They utilized elements of HSD to learn from patients and care providers as they used Adaptive Action to find their the ‘next wise step. This event led to a series of innovative solutions that are tangibly improving interdisciplinary teamwork, patient partnership, and care provider / staff experience.  A number of these solutions are now being adopted by various sites and programs.

Health communicated the challenges and rationale for setting regional expectations around the five best practices in care and discharge planning.

• Having an estimated discharge date for all patients
• Completing pre-admission screening and initiating a care and discharge plan with patient and family-centered goals and interventions within 48 hours of admission (48/6)
• Ensuring safe and regular mobilization for all patients
• Collaborating as a team through regular structured interdisciplinary rounds using the 5 key questions
• Communicating with patients and families by keeping the bedside whiteboard up-to-date (including the Estimated Discharge Date

With this ‘container’ set as the target, health service areas were invited to consider their own local solutions and strategies, based on the emergent realities of their respective communities. The ‘so what’ was considered in regional summits, Staff members explored, without judgment, various learnings in trial studies of different strategies. This allowed health service areas to explore the similarities and differences in ideas, experiences, and realities. Across the system, they connected to make meaning of their findings. Those connections proved invaluable as they acknowledged the containers, explored the differences, yet facilitated exchanges in applied learning and idea sharing. 

Following the first regional care and discharge summit, (held October 2017), attendees were inspired by the experiences of our patient partners. They committed to taking actions within their health service areas to improve care delivery based on the patients’ experience. 

We heard from patients about the impact each of the best practices had on their personal care journey, and the consequences of not applying those practices consistently. The patient’s voices were loud and clear. Their messages were simple:

• Patients and families need to be involved in discharge planning process. This supports readiness and relieves anxiety.
• Bedside whiteboards populated with plain, user-friendly language; estimated discharge dates; and checklist documentation are powerful communication tools to help patients get ready and work towards their own personal goals in their care journey. 
• Clear conversations between care teams in rounds improve both the care provider’s experience and patient outcomes.
• The tools identified should be treated as supports to the discharge process, not THE discharge experience.

The second regional summit was designed to build on what participants had learned, with the following goals in mind:

• Connect participants at all levels of leadership to the system for benefit of patients
• Review progress, commitments, and patterns
• Generate innovative solutions and showcase learning
• Renew commitments at the health service area and individual level

This led to some amazing examples of adaptive actions:

Langley General Hospital shared the profound impact that occurred when a physician noted the estimated discharge date on the patient’s chart upon arrival. It positively affected team planning and patient outcomes. This resulted in decreased length of stay for patients, increased communications with patients and care providers, and improved physician partnership during care planning and rounds.

Peace Arch Hospital demonstrated the value of keeping patients and families updated with bedside white boards during their care journey. This practice helped to avoid feelings of patient anxiety and improved team communication. It also led to greater consistency and fewer delays in discharging.

Chilliwack General Hospital showed how clear guidance on mobility planning and reinforced accountabilities helped patients avoid deconditioning. It also helped to limit other adverse events, such as hospital-acquired urinary tract infections and pneumonia. Patients were also able to leave the hospital for home sooner.

Abbotsford Regional Hospital shared how the use of a standardized five-question protocol in rounds actually decreased the amount of time care providers spent in rounds.  Initially, rounds took 60 minutes on a 20-bed unit. This has now been reduced by 50% to an average of 30 minutes, with clear discharge goals and care planning in place.  Complex discharges are now identified sooner, patients are partners in their care planning, and care providers and patients are reporting better communications and care experiences.

Burnaby General Hospital demonstrated how using patient advisors in developing whiteboard education gave rise to patient-led education and improvements. Patients and Patient Advisors led six 2-hour workshops with 40 staff members attending. These sessions included role-playing and interactive scenarios. The result of this approach was well received by the care providers and patients themselves. The use of bedside whiteboards also increased. Since the first period of tracking, bedside whiteboard use has gone up from 66% to 77%. The use of patient-friendly language has also improved from a staggering 17% to 75%. Patients reported feeling that the core principles of respect, dignity, information sharing, participation and collaboration improved at the site as a result of this training. 

Royal Columbian Hospital illustrated that by focusing on creatively building inter-professional teams with clear destinations and clinical focus areas, patients and care providers would have better outcomes and experiences. Modeled on the TV series, ‘The Amazing Race’, the team set out to improve the way they conducted inter-professional rounds. They partnered with unit leadership, and provided the requirements for what was needed in the structured rounds. They then partnered with staff to understand their concerns and developed systems of accountability for each of the roles. By the end of this launch, every member of the team completed their required competency training. Every team also submitted an additional quality improvement initiative to take forward (thus continuing the movement to the next wise action). They also developed their own self-audit tools to sustain their benefits.

Ridge Meadows Hospital’s engagement and partnership with physicians in multidisciplinary rounds focused on the harm cased to patients. This inspired a 93% rise of attending physicians during the pilot program. The resulting culture shift has inspired physicians to continue to attend rounds. A subsequent analysis of length of stay and care-sensitive adverse events is underway, though anecdotal evidence is showing a correlation and improvement of physician attendance in rounds and improvements in these areas.

In summary, the summits were an opportunity to act collectively to:

• Examine patterns in the system (shifting from a toolset to a mindset approach)
• Empower sites to be responsive to opportunities emerging from old and new patterns
• Build adaptive capacity by creating a space for generating and sharing innovative ideas
• Act as both teachers and learners: Participants, showcasers, and patients were both teachers and learners throughout this approach
• Build adaptive capacity in the system
• Take action / make decisions that inspired attendees to champion the work and bring others with them
• Be open to self-organizing

The message at the end of these summits was clear:

You have the power to create conditions for self-organizing patterns.

In turn, we, as organizers, have learned that acknowledging these patterns and shifts equates with increased trust and engagement at all levels of leadership. By also recognizing the finite containers (targets, fiscal constraints etc.), the summits were able to open up infinite possibilities by noting that healthcare transactions are actually partnerships - not zero sum or finite games, but shifting and non-linear / infinite experiences. The summits allowed staff to shift from a mindset of “unsolvable problems” to “infinite possibilities,” when explored with appreciation and partnership. In the end, the summits have shown that there are multiple interactions that are interconnected and produce system-wide patterns. Our work was to create the opportunity for those conditions to flourish.

Lisa Bournelis, BA, MA, CCMP
Senior Consultant, Strategic Transformation Team
Fraser Health Authority