Ortho-Joint Moves the Needle on Timely Discharge
Helping patients plan for their hospitalization and recovery well in advance of surgery has improved discharge by noon rates for the Ortho-Joint service line.
When the Orthopaedic-Joint surgery department decided to take the process improvement plunge, it quickly learned that many of its barriers to discharge were controllable. Most orthopaedic surgical procedures are elective, and scheduled four to six months in advance. For that reason, this particular service line was ripe to test a hypothesis: Could better pre-surgical care coordination and earlier patient education improve discharge by noon and discharge to home rates?
Starting in August of 2015, individuals representing every step in the total hip and knee arthroplasty episode of care met in two separate three-day workshops to first analyze their current state, and then to create future work processes. The group was led by physician champion James Huddleston, MD, and included representatives from physical therapy, case management, nursing, clinic staff, surgery schedulers, advanced practice providers, navigation services, Performance Excellence and SHC leadership.
One year after beginning the process, the Ortho-Joint service line has reported an eight-hour decrease in length of stay, a 17 percent increase in its discharge by noon rate and steady improvement in its service scores. Getting more patients discharged to home rather than to a skilled nursing facility (SNF), however, has proved more difficult to achieve.
“Right now, demand exceeds capacity, so anything we can do to minimize this imbalance is important,” said Huddleston, associate professor of Orthopaedic Surgery, adult reconstruction service chief and former medical director for orthopaedics. “This project has been informative in that we now have a clearer understanding of the barriers preventing more patients from being discharged to home rather than to a skilled nursing facility. And with this information, we can take steps to optimize our processes, namely to increase both preoperative and postoperative resources on the case management side.”
From the outset, the team set very attainable goals—increase the discharge by noon rate to 40 percent, increase the number of patients discharged to home to 70 percent and improve Press Ganey scores in the area, “Staff works well to care for you.”
The group targeted the steps that it could control in pre-surgical clinic visits and inpatient care after surgery. “There are a number of barriers that are impeding our patients from progressing through their care,” said Tina Orlando-Cortez, performance improvement consultant. “What we saw in our workshops was that a lot of our discharge planning was really reactive.” We were bombarding patients with questions after their surgery, she said. Do you have someone taking you home? Do you have a family member to help you? Who is getting your home prepared? Do you have insurance to cover a skilled nursing stay? The improvement team questioned why these issues couldn’t be addressed earlier in the process. It then redesigned its workflows to bring discharge planning to the forefront, adding staff to support three new roles in the clinic.
When a patient makes the decision to have surgery, a number of new processes now kick into gear. First, physical therapy works with patients before surgery, using pre-habilitation as a way to improve their strength. Secondly, case managers help patients plan for their recovery. They arrange for care and equipment at home, ensure that patients have transportation to and from the hospital and assist them with securing medical clearances before their pre-op appointment. The ortho-joint clinic also added a patient navigator, who calls surgical patients one to two weeks before their pre-op appointment to ensure that they have done everything they need to be ready for surgery. The navigator is available to help patients finalize medical clearances, obtain insurance pre-approval and identify any financial constraints before surgery.
“Getting all of these items planned for in clinic, long before surgery, was the biggest change we made to the process,” said Cortez. On the inpatient side, the team discovered that the biggest delay to discharge is transportation, not having someone available to drive the patient home at the time of discharge. Patients being discharged to SNFs were consistently discharged on time, since transportation in these situations must be scheduled in advance. So the team developed a new plan for its ortho-joint surgical patients: it now assigns a discharge date and time before surgery. This ensures that family members can arrange their schedules in advance to be available to pick up at the designated time. Ortho-joint patients are also given a Patient Plan, which is visible in the patient room and to the caregiving team. This laminated checklist outlines all the milestones the patient must achieve before being discharged. Both of these improvements give the patient and the inpatient care team a goal to work toward, said Cortez.
“One of the most important lessons we learned was that given the complexity of the current workflow, it is much more difficult to make and sustain changes than most people would think at first glance,” said Huddleston. “You need to get multi-stakeholder buy-in to sustain the gains. But any service line with a fairly consistent workflow would be amenable to this type of work.”