Topic: Quality Improvement vs Patient Discharge
This chat is over, but you can see the #MEQAPI storify thread
Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.
Patient handoff and discharge are two of the most risky events in the patient journey through the care process, and account for the lion’s share of mistakes and missed opportunities. Incomplete or incorrect information transfer, (or failure to transfer at all) can result in sub-optimal patient outcomes, injury, or death.
There are many different risks, issues, and opportunities related to patient discharge, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patients.
- Knowledge Deficits at ED Discharge
- Predicting Home Discharge After Surgery
- Post-Op Weekend Admissions & Discharges
- Discharge Considerations After Minor Head Injuries
- Self-care after hospital discharge: knowledge is not enough
- Physicians Practice: Discharging Problem Patients
Standardizing the patient discharge process and making it a “no interruption” activity can reduce risks due to distraction, multitasking, and missed steps, while also reducing missed opportunities. Patient discharge also has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm.
Quality Improvement approaches can greatly increase adoption and effectiveness of standardized discharge processes by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove obstacles to adoption and compliance.
We will take a QI approach, and discuss the next topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.
Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:
- Policies: either unit, office, organization, or national policies
- Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps in discharge, etc.
- Insurance Models
- Machines (equipment, EHR)
- Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
- Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
- Staffing: insufficient or unqualified staff
- Training: insufficient base training, incorrect training, insufficient CME, etc.
- Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
- Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
- Supplies: medical or office, inferior fax paper, lack of coffee(!)
- Data? – sent to wrong recipient, not shared with pt or specialist, etc.
- KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
- Poor quality and safety metrics
- Targets: improper or unachievable performance targets
- Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
- Noise: distracting noises, sound levels too high, etc.
- Space: cramped, uncomfortable, slippery surfaces, etc.
- Time: Too little time per patient, too little time in a day, too many demands
- Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.
The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.
- What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a bad patient discharge
- What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a bad patient discharge
- What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a bad patient discharge
- What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a bad patient discharge
- What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a bad patient discharge
- What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a bad patient discharge
MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.
To quote the IHI on what the Triple Aim encompasses:
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.
The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.