Joe, although I fully understand your points about patient selection, I do favor front end rules. I think they help identify patients where it is safe to proceed. As you said, though, there are many who really do need a procedure to continue to function. We are trying to develop a hybrid model for our total joint program. We will have rules; patients who meet the criteria can be scheduled by their surgeon. Patients who do not meet the criteria can request an exception. Exceptions would go to a panel of clinicians who review the case, the risk factors, and decide whether that patient is well enough to proceed with surgery. It takes the selection process for high risk patients away from the surgeon (which is often wanted by the surgeon) and on the system.
I think this is an ideal opportunity to develop a “Speak Up” policy directed towards behavior (vs. the classical use of direct patient safety). Coaching junior staff on how to directly, immediately address negative behavior, and making sure leaders are on board and will fully support this, will have a powerful impact. She needs to see and feel the culture has changed. She needs to see the junior staff have been empowered to “Speak Up”, and that leadership will support them through that. It often takes only one or two events backed by leadership to change behavior.
I agree with Erik – working with the local neighbors/politicians will be important. How do you get employees from parking on the street? Is there a compromise somewhere in there…local, temporary parking lot for you…no on street parking of employees for them?
Is the ramp for patients/visitors only?
Could you share some of your data? Things such as –
1. Readmission rates reduced from what to what?
2. Mortality rates decreased from what to what?
3. How often were the home visits?
4. How long to BP control, on average? 90 days? 180 days?
5. Could this have been accomplished in less time?
6. Could this be accomplished with a blend of home and office visits?
7. Home PT/OT? How often?
These CMS grants can be difficult…find costly successes, but then funding dries up. I think if you look at the data carefully, you may find the things that were the highest “bang for the buck”, eliminate things with a lower ROI, and get the project close to cost neutral.
We have worked on this as well. Some of our implementations which had success –
1. Built an “anticipated DC within 24 hours” order. This fires tasks to –
a. Nursing: finish patient education, identify caregiver for education, notify ride, start teach back
b. Unit Secretary: schedule follow-up appointments and tests
c. Case Management: arrange appropriate DME
2. To go lunches – patients get two “to go” lunches when they leave before noon – one for them, one for their ride
3. Physician Dashboard – percent DC orders completed before 1030, with goal of 50%
4. Community education with local skilled nursing facilities/adult family homes with limited success
We were having success with this (13% DC before noon to around 30%); we recently changed EMRs, and workflow has expectedly changed with it. We also lacked our tracking dashboard; the new one has not yet been built.