Page 4 - 2016 Nursing Annual Report | Summa Health

Transformational
Leadership

Managing the care
transition

One of Summa Health’s major initiatives over the past several years has been to
improve the management of patients during their stay. Lanie Ward, MBA, BSN, RN,
NEA-BC, System Senior Vice President for Patient Care Services and Chief Nursing
Officer, was named the senior executive to oversee a multidisciplinary group tasked
with finding new ways to accomplish that goal.

Nurse led daily Plan for Your Day/Plan for Your Stay “The TCC role is key to the movement of patients and
rounds were one of the first things implemented and making sure the plan of care, not just the discharge plan,
were later moved to the patient’s bedside with patient and is completed within a timely framework and that the
family involvement. “We moved them bedside so that the patient has the preparation they need prior to leaving
patient and their family would be involved in the plan and the hospital,” said Carolyn Holder, MSN, RN, GCNS-
better understand expected treatments and length of stay. BC, System Director, Transitional Care and Utilization
For example, a patient with pneumonia will stay about Management.
three days. Now the nurse can say to them, you’ll likely be
headed home in about three days,” said Ward. In October 2015, the model was redesigned to have TCCs
focus on patient care. Responsibilities related to health
She said in the past, nurses were not informed about the insurance were eliminated. “By January of 2016 we were
expected length of stay for a particular diagnosis, so now already meeting our targets, so this is the model that
they are included on a report provided by the coding staff. works,” said Holder.

As part of continuing improvement initiatives, electronic In order to improve the discharge process, Holder’s team
visibility boards were placed in the inpatient units and are introduced the IDEAL Discharge Preparation Checklist in
utilized during the daily Safety Huddles to identify and the fall of 2016.
resolve barriers to patient discharge. Transitional Care
Coordinators (TCCs) report on the number of observation Include the patient and family as full partners in the
patients in house, how many are being converted to discharge planning process
inpatient status and any diagnostic, treatment or transition Discuss with the patient and family 5 key areas to
delays that need to be addressed. prevent problems:

Another initiative expanded the number of TCCs to cover 1. Describe what life at home will be like
all of Summa Health’s inpatient units and the Emergency 2. Review medications
Department seven days a week. They are Registered 3. Highlight warning signs and problems
Nurses who serve as the leader of the transitional 4. Explain test results
planning team, collaborating with social work for complex 5. Make follow-up appointments
patients and case managers for targeted populations.
Educate the patient and family in plain language
TCCs review cases daily as part of the Plan for Your Stay about the patient’s condition, the discharge process,
rounds and are the “go to” person for the physicians, and the next steps at every opportunity throughout
knowing and guiding the plan of care. They complete the hospital stay
a transitional care assessment, review the current plan
and ensure gaps are addressed. Based on the initial Assess how well doctors and nurses explain the dx,
assessment, the TCC identifies the plan for discharge and condition and the next steps using teach back
monitors that plan for changes or barriers.
Listen to and honor the patient/family goals,
preferences, observations and concerns.

Source: Agency for Healthcare Research and Quality

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