Collaborative Multi-Disciplinary Rounds (MDRs) Drives Length of Stay Reductions
- Length of Stay (LOS) reduction is a key strategy for patient cost containment, and communication among care providers is essential for coordinating LOS variances. Lean Collaborative Rounds foster communication among care providers and standardize a workflow for Discharge Planning that drives LOS reductions.
- Fiscal Year (FY) 2016 average LOS was 6.65 days. This was more than 1 day greater when compared to established benchmark ratios. With increased pressure to meet or break Medicare even, meeting benchmark expectations is essential to remain fiscally viable.
The Colon Rectal and Urology Medical Surgical Unit at a Hospital will reduce the Average Length of Stay by 1 day, from 6.65 days to 5.65 days, between July 1, 2016 and June 30, 2017 by:
- Implementing Lean Principles for Communication
- Defining and Standardizing Roles for Discharge Planning
- Implementing Collaborative Multi-Disciplinary Rounds (MDR)
- Including the Patient and Family Early in Discharge Planning Process
Patient and Family Centeredness Implications
- Patients enter a hospital trusting that staff will do the right thing to help them return to their previous lifestyle in the same or better condition within reasonable timeframe.
- Empowering staff with the tools to direct and communicate with patients regarding the discharge process enhances the patient’s experience.
- The new process engages the patient at time of admission, empowers them to be a co-owner, and provides a framework for collaboration among staff. The patient now has experts involved that are needed to achieve everyone’s goals for discharge.
- Percent Daily Round Attendance
- Benchmark (Observed / Expected) ratio reconciliation for every patient based on their coded diagnosis and associated benchmark LOS
- LOS overall
- With the bedside leader involved in multidisciplinary rounds they can effectively communicate the plan of care with the patient, the communication with nurses increased by 6.5% (from 75.5% to 80.4%).
Rapid Cycle Improvement: Cycle 1
- Plan: Staff were engaged in May 2016 by reviewing data, identifying barriers, and proposing interventions for discharge planning but not involved in MDR. Second, lack of standard place for all disciplines to document plan of care. Third, Enhanced Recovery after Surgery (ERAS) patients identified.
- Do: In July 2016, staff launched a standardized paper report sheet for Managers and Charge Nurses to review the daily progression plan for all patients. Education roll-out regarding standard documentation area in the electronic health record. Include standards of care for colorectal patients in MDR discussions.
- Check: Observed/Expected ratio decreased from 1.56 to 1.26. Physicians, Comprehensive Care (CCM), and Therapy audited standard documentation expectations.
- Act: After staff input was reviewed, bedside staff were included in the MDRs with CCM, Physical Therapy, and Physicians to enhance communication.
Rapid Cycle Improvement: Cycle 2
- Plan: By August 2016, paper report sheets became a nuisance to control and often were not completed by off-shifts or lost completely. Staff reconvened and with the assistance of Lean experts, staff were exposed to Lean Visual Management Tools for communication.
- Do: In August 2016, frontline Staff launched a Lean Visual Management Communication Board/Multi-Disciplinary Round Board for collaborative discharge planning that all staff could see, including physicians. The focus of the board was identification and mitigation of discharge barriers. Visual Standardization of Communication was adopted for the board in the form of symbols for specific barriers.
- Check: All staff had access 24/7 for discharge planning information which helps direct patient discharge discussions with patients as well as families. The MDR board was utilized 100% of the time during Multi-Disciplinary Rounds. Observed/Expected ratio decreased below the 1.0 benchmark.
- Act: The MDRs as well as the MDR board has been adopted and continues to be refined. The MDRs have proven to be an effective tool for communication and barrier/challenge identification to help drive discharge planning and ultimately reducing LOS.
Length of Stay Reduction (LOS)
- Reduced average LOS by 1.07 days (16% decrease)
- Reduced ALOS/AMLOS ratio from 1.15 to 1.01 (12% decrease)
- Total savings Year to Date equaled $390,818
- Projected annual savings equaled $521,091
Importance of Results
- Aligned with the hospital’s initiatives to reduce LOS throughout the facility for FY17 and moving forward to FY18.
- With the increased pressures related to reimbursement – providing high quality, high service, patient-centered care all while improving efficiency is of utmost importance to remain fiscally viable.
The team will continue to sustain and improve costs by:
- Continuing to drill down at the Multi-Disciplinary Rounds (MDR) to identify barriers and opportunities for improvement.
- Identifying the barriers at the (MDR) and using the Lean Huddles to problem solve issues at the bedside.
- Continue to monitor weekly length of stay metrics.
- Spread lessons learned throughout the facility as the MDRs are rolled out facility wide.
- Continue to educate all new clinicians as they join the hospital team.
- Reward and Recognition as the team reaches milestones with all disciplines.
- The current collaborative lean communication huddle board is a manual process. Next steps are to implement an electronic solution.
- Tracking software has the capability to mimic fields and information listed on the communication board. This will enable live updates that can be entered and viewed by any staff in the organization at any time, not only when they are physically present on the unit viewing the board.
- Common cause variation for the LOS ratio above the goal has been noted when known long term patients discharge.
- This project has proven that daily benchmark LOS review, barrier discharge identification and mitigation, and collaborative communication drives discharge planning and positively affects LOS goals.
- Visual Management, standardization, and setting standard roles and responsibilities is essential to successful implementation.