Process Breakdown Analysis and Improvement

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Process Breakdown Analysis and Improvement

Kate Zetler, CORE


CORE DSAA Snapshot

• 155 Hospitals• 5 Transplant Centers• 13 Trauma Centers (Levels1 &2 )• 1 Free-Standing Pediatric Hospital


Process Breakdowns 1st-3rd Quarter

2%

1% 1%

4%1%

0%

11%

0%

79%

1%

Body Released

Communication with CORE

Communication with Hospital Unit

Funeral Home

MD/Physician

NOK/Family Contact

Non-Designated/Early Approach

Patient Care Issues

Timely Notification/Late Referral

Unknown PBD Selected


First Three Quarters by the numbers…

Ruh-Roh!


PBD Totals by Hospitalswith 10+ PBDs

ALTOONA REGIONAL HEALTH SYSTEM - ALTOONA CAMPUSBUTLER MEMORIAL HOSPITAL

CHARLESTON AREA MEDICAL CENTER - GENERALCHARLESTON AREA MEDICAL CENTER - MEMORIAL

CHILDRENS HOSPITAL OF PITTSBURGH UPMCJAMESON MEMORIAL HOSPITAL NORTH

SAINT VINCENT HEALTH SYSTEMSHARON REGIONAL HEALTH SYSTEM

UPMC HamotUPMC MERCY HOSPITAL

UPMC PASSAVANTUPMC PRESBYTERIAN

UPMC SHADYSIDE CAMPUSUPMC ST MARGARET

WEST VIRGINIA UNIVERSITY HOSPITALSWHEELING HOSPITAL

WPAHS ALLEGHENY GENERALWPAHS WEST PENN HOSPITAL - FORBES REGIONAL CAMPUS

0 20 40 60 80 100 120


4th Quarter Action PlanAGENDA: To reduce Process Breakdowns (timeliness of referrals*) by 60% before year end 2012.Action Steps:

- Responsibility will be of the individual PSLsTimeline:

- September 1 – December 31, an analysis and interventionsResources:

- Modified and uniform presentations to deliver to hospital staff in-services- Implementation of regular use of clinical trigger cards to be distributed when rounding, in-services, any education opportunities.-Immediate follow-up (within 24hrs) with key contacts at hospitals when an “Untimely Referral” is made.- Dashboard used to reinforce Process Measures at individual hospitals- Straight-forward definitions of a “Process Breakdown”- Follow up with attending physician within 24 hours of donor case- Increase of PSL availability on the units to develop relationships.


Specific Area for ImprovementEffective Request

• Children’s Hospital of Pittsburgh– Large level one trauma center, only free standing

children’s hospital in the region. – Current issues with early mention to families from

previous designated requestors and other CCMs– Escalated in 2012, resulting in poor conversion rate

through the 3rd quarter (52.3%Effective Request)– Something had to be done


Seed Statements & Effective Request

• A way for the physicians to become involved…– We wanted the CCMs to be

involved in the approach, but not before a huddle process and discussion of the options

– CCMs wanted to be able to give the family a “Heads up” that another discussion was coming

• Part of the issue between this hospital and CORE was the feeling that CORE was trying to “take care away” from the medical team.


What we did…

• Multiple meetings between Director of Professional Services and professional service liaison with “repeat offenders”

• Met after every early mention• Discussed the use of “Seed Statements”

difficult situations• Some acknowledgement by the hospital

that early mention hurt the donation conversation.


Bold Requests in Action!

Bold Requests from Children’s Hospital DAG 1. Need for more consistent communication/ more inclusive huddle between OPC and CHP staff.• “Star Contact” Initiated

– Nursing Supervisor to be contacted as soon as the OPC arrived on- site

– Nursing Supervisor responsible for gathering Huddle Team and meeting in a “safe place” to discuss donation steps


Bold Requests in Action!

Bold Requests from Children’s DAG 2. CHP recognized that virtually none of our OPC staff ever worked in pediatrics, less than half were nurses.

– CHP offered a “Welcome to Pediatrics” course for OPC staff to attend to learn about the difference between care of adults and pediatrics

– CHP staff felt that we finally “heard them out”, OPC staff had a better understanding of the pediatrics healthcare team


CHP Results!


DSA Results…

3rd Quarter

4th Quarter

Type of PBD Number of

Body Released 6

Communication 4

Funeral Home 16

Hospital Approach 23

Physician 2

No Call Prior to Ext. 4

Untimely Referral (over all)

252

Total 307

Type of PBD Number of

Body Released 6

Communication 6

Funeral Home 4

Hospital Approach 19

Physician 1

No Call Prior to Ext. 5

Untimely Referral (over all)

168

Total 204

33% Decrease


Moving Forward

• How can the hospital’s own this?• How do we shift donation to a “hospital led

program”?


Community of Practice Council

• New to the HD Department– Weekly Pull Call

• New Ideas from the 2-29 meeting– Clinical Trigger Cards for specific units (MICU vs.

CICU vs. TICU)– System Wide interventions and DAG– Process Breakdown Audit Tool


Thank you!

Process Breakdown Analysis and Improvement

Documents

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