Apr 9 2014

Improving safety for patients on warfarin therapy

Orthopaedic Surgery/Anticoagulation Service partnership helps meet National Patient Safety Goals for high-risk medication

A partnership between the Department of Orthopaedic Surgery and the Anticoagulation Service improves patient safety for orthopaedic patients who are on high-risk/high-alert Warfarin therapy.

Brian Kurtz, PharmD, and Shelley Howells, LPN, from Anticoagulation Services, discuss a patient referral.

Post-operative Orthopaedic Surgery joint reconstruction patients typically receive anti-clotting medications such as Warfarin (Coumadin) to prevent deep vein thrombosis (DVT)—blood clots in the calf or thigh. This is a life-saving but high-risk/high-alert medication because staff must closely monitor the therapeutic levels in the blood.

In fact, the Joint Commission has made reducing the likelihood of patient harm associated with anti-clotting medications a National Patient Safety Goal.

Back in 2012, U-M faculty, staff — and most importantly patients — were dissatisfied with the level of management this high-risk population received. So, in January 2013, a multidisciplinary team formed to tackle the issue – as one of the inaugural “Lean – Train the Trainer” Projects under the Michigan Quality Initiative.

Using several lean tools, the team identified tasks within their control that they could change to improve the process to identify and monitor patients—and to get them started in the service.

“After several meetings, we aligned clerical work with clerical staff and significantly reduced the involvement of the clinic/phone triage nurses and Joint Service mid-level providers associated with managing these patients,” says Dorothy Nalepa, administrative manager of the Taubman Center Orthopaedic Surgery Clinic. Read the rest of this entry »

Mar 19 2014

Operating room whiteboards help fight infection

Sometimes the best solutions are right before our eyes

Since the 1960s it has been known that certain procedures — such as hysterectomies and colorectal operations — run a high risk for infections, and that if surgeons use prophylactic antibiotics during these surgeries, infection can be avoided.

Now, the Health System hospitals operating rooms are using electronic whiteboards to inform OR medical staff of each patient’s antibiotic needs.

“We had already put up these giant screens in the ORs to show the patient’s name and procedure, and it occurred to us that we could put the screens to even greater use by adding the specific antibiotic individual patients should receive based on the procedure they are having,” says Mark Pearlman, M.D., professor of obstetrics and gynecology, and head of the OB/Gyn portion of the project. Read the rest of this entry »

Mar 5 2014

Safety Huddles: Sports tactic makes U-M hospitals safer, more efficient

University of Michigan hospitals are using a classic team tactic—huddles—to make things safer and more efficient for patients and staff.

These huddles are safety huddles—daily morning meetings that prep staff on necessary information, including patient admissions and discharges, problems with equipment, medication changes, support services, supplies and more. They run Monday through Friday, from 8:45 a.m. to 9 a.m.—a brisk 15 minutes—right after bed briefing.

Chris Dickinson, M.D., professor of pediatrics and the co-architect of patient safety huddles, leads a morning huddle to help staff make the hospital safer and more efficient for patients and staff.

Although the safety huddles have never been mandatory, “everybody wants to come,” says Scott Marquette, intermediate project manager at U-M C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital. A typical meeting includes charge nurses, ambulatory care bed managers, laundry managers, support staff, biomed, Office of Clinical Safety and MCIT (Medical Center Information Technology)—in short, everyone with information to give to others and/or a need to know. Marquette sends information gleaned from the huddle to 190 managers and staff across Children’s and Women’s via email. Staff who want to be added to the email list should email Marquette.

“Like all hospitals, we have safety concerns,” says Chris Dickinson, M.D., professor of pediatrics and the architect, with Marquette, of the safety huddles. “To get people thinking about safety, you really have to change your culture. The safety huddles get people thinking about safety all the time. We talk about all sorts of error prevention strategies.” Read the rest of this entry »

Oct 22 2013

Improving work, enhancing care

CVC unit benefits from new Care Management model

This summer, the U-M Health System began improving how care is delivered to our patients through an initiative called Care Management.

Previously, discharge planners and social workers were assigned to specific services throughout the U-M Hospitals and Health Centers. Now Care Management designates a social worker and discharge planner to assist each unit based on where patients are located. Through the model, RN case managers are physically present on their assigned unit, connecting with patients, teams and providing support.

The initiative began in August with rollout on inpatient units in 5A, 5B 7C/D, CVC4 followed by implementation on all C.S. Mott Children’s Hospital inpatient units on Sept. 16.  Following implementation, teams have been rounding and working with individual units to determine what is working well, and identify issues for resolution.

Christopher Title, RN, BSN, clinical nurse supervisor at the Cardiovascular Center on ICU CVC 4, has already begun to see improvements on his unit.

“This initiative has changed our workflow in a lot of positive ways,” says Title.  “It has increased communication and made the process for transferring patients out of our unit more efficient.”

“The Care Management model has allowed us to better identify the patient’s transitional care needs and move them through the system quicker.”

As part of Care Management, Title’s team comes together each weekday to discuss the patient plan for the day, the plan for the patient stay, potential barriers to implementing the plan, along with clarifying assignments of members.  The daily team “huddle” consists of the advance practice team, charge nurse, case manager, social worker, nursing management representative, and bed coordinator.

Title says, “this type of daily collaboration and communication has led to improved transitional care within our facility, the right care in the right location for our patients, along with reducing the transfer times to outside extended care facilities” – important objectives of Care Management.

“When caring for patients, focusing on the family is always a priority,” adds Title. “Our CVC-ICU social worker Liz Rodems now works with case manager Cathy Kolpacki to identify issues like how patients will get home and who will to take care of them during those care transitions.  In addition, our charge nurse works closely with all team members to assure transitional care needs are met.”

In addition to improving patient care, the program is improving staff workflows and satisfaction.

“It has been great to have Liz and Cathy right on our unit,” says Title.  “We used to have to page or call a social worker and wait for help.  Now they are there every weekday to help. Our staff loves that.”

What is Care Management?

The goal of unit based Care Management is to improve communication and coordination of care through integration of discharge planning, utilization review, social work and more even distribution of case manager workload. In addition unit-based case managers and social workers are expected to interface with nursing and other care team members on the unit each day to ensure the plan of care is communicated and carried out in a timely and efficient manner as well as to ensure smooth transitions of care at discharge. They will coordinate with outpatient providers, home care and other services.

Additional information about Care Management, including resources and communication updates, can be found at http://www.med.umich.edu/i/caremanagement/

Dec 20 2012

Anatomic Pathology’s lean learning path

For a patient anxiously awaiting lab results—the good news, or the bad—time is of the essence. Learning that their tissue specimen was lost would be horrible.

“We aim to put patients first. That’s why we focus on breakdowns in process,” says Jeffrey Myers, M.D., A. James French Professor, and director of the Divisions of Anatomic Pathology and MLabs. AP provides diagnostic and consultative services in the areas of surgical pathology, cytopathology, neuropathology, dermatopathology, and renal and autopsy pathology for U-M and outside health care organizations.

The last time the Division of Anatomic Pathology lost a specimen was 1 year, 25 days ago, and counting. It’s an amazing feat considering that AP processes about 85,000 pathology specimens a year—and that every single one of those specimens goes through 17 separate steps.

Dr. Jeffrey L. Myers, director, Anatomic Pathology and MLabs, and John Perrin, quality assurance coordinator, Department of Pathology, stand in front of the “No Time to Lose” clock outside the Anatomic Pathology and Histology labs in the main hospital. The clock is Myers’ brainchild, and Perrin has the key. Every day, the AP team works to prevent errors—and no one wants to restart the clock.

If you do the math, AP’s current risk of losing a specimen is 2.94 per million opportunities. Their performance surpasses the Six Sigma level, the quality standard of “near perfection.”

They credit their success to a lean journey that began when Myers took the helm in 2006. Myers came to U-M from Mayo Clinic, where he also led lean endeavors.

By 2007, Myers began introducing lean training, lean teams and onsite gemba walks throughout AP that have paid off big by reducing lost specimen errors for weeks, months, years at a time—and by reducing lead times for selected services by 50 percent.

AP’s average turnaround time went from 7 days in 2005 to about 3 days currently.

These improvements occurred while AP’s workload rose 25 percent—from approximately 68,000 specimens in FY2007 to about 85,000 in FY2012.

As a result of lean thinking, AP has:

  • Implemented an operating room (OR) runner to bring specimens to the lab, freeing up OR nurses to spend more time with the patient. For permanent specimens alone, average time of delivery fell from 1 hour, 19 minutes to 7 minutes—an 88 percent decrease.
  • Eliminated the opportunity for specimens to go missing by creating an action plan to limit distractions for lab staff, reorganizing the lab bench to work towards single piece flow, and standardizing workflow.
  • Developed a lost-specimen policy and orienting new residents, pathology assistants, histotechnologists, fellows and faculty.
  • Created an environment in which technicians are encouraged to “stop the line” and ask for help when they are having difficulty with a piece of tissue. Read the rest of this entry »