Criteria-led Discharge: from a solo effort to a team-based decision
Submitted by Jessica Hainstock, Communications Specialist, Communications and Public Affairs
In its simplest form, Criteria-Led Discharge is a pre-printed form that enables a physician to identify the criteria that need to be met for discharge – knowing that once those criteria are met the patient is officially discharged. That plan is then shared with everyone in team rounds, and consistently monitored and updated by all members of the care team for a window of up to 72-hours.
However, as straight forward as it might be in execution—printing out and filling in a list of criteria—the collaboration, communication and trust needed for a CLD process to work well takes time and commitment by everyone involved.
The Importance of Relationship
First read about in The Advisory Board Company’s “Discharge Strategy Handbook” (the Company is an international consortium of health care best practice for knowledge translation and spread literature, of which PHC is a member), Criteria-led Discharge (CLD) stood-out as a potential way forward for the Medicine Program to standardize access, flow and patient placement – something that the program had started to tackle in 2016 with MOET, or the Medicine Operational Excellence and Transformation project.
However, ensuring that the relationship required for something as collaborative as CLD was in place, prior to starting, is an important part of what is making this process a success.
“I think the foundation for CLD is trust and relationship between the CMR/physicians and the Medicine Program,” says Stella Tsang, Performance Improvement Consultant for MOET. “Marco Catalano, in his role as the Flow & Access CNL on Medicine, seized the opportunity to strengthen trust and build a relationship with this group by working together to address inflow issues that have impact on the physician group’s work.”
Building on the success of earlier collaborations with the CMR like the Triage Order and Admission Hybrid Model, Marco brought forward the idea and template for CLD to Dr. Steven Pi. Together, Dr. Pi and Marco worked together to refine the order set and implement CLD on Medicine, which is work that has been seamlessly picked up by current CMR, Dr. Vesna Mihajlovic.
“There’s been a lot of buy-in, which I think is derived from the recognized value in this form and in this process,” says Dr. Jane McKay, Associated Physician Director, Medicine Program. “Shifting the discharge of medically-sound patients from a solo effort to a team-based decision has increased communication, confidence, trust – ultimately it’s empowered the team and the physician to be confident in the decision to discharge without necessitating a physician to have to lay eyes on a patient prior to leaving.”
No one is taking any chances
Patients are identified for CLD in daily team care rounds; however, it’s important to note that not every patient is a candidate for CLD and that each list is only valid for 72-hours.
“We see this process as a commitment to discharging but not an absolute,” says Marco. “No one is taking any chances. If even one of the criteria can’t be met, we’re not discharging that patient and are calling for a reassessment.”
And if that is the case and a condition of discharge has not been met once those three days have passed, it’s back to the drawing board.
Patient White Boards
One of the neatest complements to the CLD work is the incorporation of the patient whiteboard.
“We are using it as a communication tool between staff and patients, so that everyone is aware of what benchmarks need to be met before a patient can go home,” says Sandy Barr, program director, Medicine.
The goal is to have staff record the outcomes of the CLD form onto the whiteboard, where patients and families can engage in and ask questions about the benchmarks for both their care and personal plans. These conditions can range from needing to secure a shelter bed, to hemoglobin counts needing to be greater than 90, to the patient needing to be able to climb two flights of stairs.
This transparency and awareness can serve as a motivator, a talking point, and a reminder of the goals that everyone, including the patient, is working towards. It also helps the family to plan for their loved one’s transition back home, or onto their next level of care, as they have been part of the discharge planning along the way.
Where it fits
Gone are the days of needing to call or page a physician for a discharge order. Having a physician put a patient’s discharge plan on paper not only helps to shed light on the hurdles that require conquering, it also helps to prioritize work. Everyone commits to what it’s going to take to get a patient home and the timeline in which they have to do it.
“When a physiotherapist knows that all that’s standing between a patient and them going home is the ability to walk 60 steps, working with that patient to meet that goal becomes the focus,” explains Julie Kille, patient care manager, Medicine Inpatient Units. “When we know both the medical and the allied conditions for discharge we’re able to better plan because we knew the day before that the patient was good to go.”
Thanks to the introduction of this tool and Marco’s work championing it, Medicine is working towards having approximately 30% of the program’s discharges before noon.
“This means that our beds start to become available earlier in the day creating more timely and efficient movement of patients waiting to come to our units. Patients don’t wait as long and staff workload is smoothed throughout the day,” says Sandy.
Not being able to move patients when they’re ready means that our patients’ needs aren’t being met in a timely manner, which creates inefficiencies and congestion in our system, which results in us missing our Pay for Performance targets. And that means missing the financial incentives that come with hitting those targets.
In short: the impact of inefficient flow on our patient outcomes and financial performance is significant.
CLD: Is it right for your program?
Perhaps one of the most significant benefits is that CLD is a model easily transferred to other programs. The checklist tool itself is designed to be generic so that it can be adapted to any program area.
If this sounds like something you would like to introduce to your program area, you can look at the CLD order itself in the Forms catalogue on SCM (PHCPH732) or reach out to Marco (MCatalano@providencehealth.bc.ca) for more information on how to make it happen.
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