We have noticed that upon discharge from hospital there is no communication between hospital staff and St. Jude staff which creates a safety problem.
We will increase communication between hospital, health service providers and St Jude staff regarding discharge with a minimum of one contact per hospitalization for 100 percent of hospital approved discharges by January 2018.
EQIP Support to the Project
- QI coach: Tara McKendrick
- Data Coach: Abel Gebreyesus
St. Jude Community House is a supportive housing provider in Toronto with 92 units open 7 days a week. Support staff are onsite 12 hours each weekday, and eight hours on weekends, with a caretaker on call 24/7.
Although transitions in health care are often where continuity of care falls through the cracks, the transition to supportive housing – which isn’t well understood by most health care providers – is even more challenging.
For the staff at St. Jude’s Community Homes, they saw this lack of coordinated discharge planning between them and the hospital as more than a nuisance – it was causing safety issues for them and their clients.
When the opportunity to get involved in the EQIP initiative came up, St. Jude’s was quick to respond seeing this as an opportunity to tackle a long-standing problem.
According to Shannon McCauley, Project Lead, the QI tools they learned how to use through the EQIP project were incredibly helpful in “getting past the frustration that we can’t effect change in the hospital, and got us focused on what we can do.”
St. Jude’s used the Fishbone diagram as their diagnostic tool, and it “created much needed clarity to our known problems,” explains Shannon.
The root causes were identified as:
- Lack of Education and awareness of St. Jude and supportive housing within hospitals and other health service providers
- Lack of clarity of staff role and gaps with access to supports
- No central system for staff to receive phone calls after hours
- It’s not simple for outside support and residents to access staff if their assigned worker is off site
Using a driver diagram, they were able to dig deeper and begin identifying change ideas.
Their next steps are to start testing their change ideas using PDSA– Plan, Do, Study, Act – cycles, and creating run charts to monitor their process measures. One of the biggest change ideas is creating a single point of access for St. Jude’s staff, which they will be testing through a PDSA starting with one Health Service Provider. And they’ve identified a few more:
- Creation of a flow chart for staff when a resident is hospitalized
- Include a line in the job description for resource staff to answer the general support phone line
- Create scripts for answering the phone, redirecting calls and voice mail messages directing callers to new numbers
By streamlining the process for health service providers and clients to contact the staff at St. Jude’s Community House, clients will experience an easier transition back to their homes, and hopefully reduce the rates of re-admission to hospital because of the lack of follow up care.
Through their involvement with EQIP, St. Jude’s is hoping to make a habit of quality improvement.