For just over 55 days, we’ve been talking about all the work that Ready Every Day Team 2, Transitions of Care, is doing, but did you ever stop and think about just how many different care and service areas and people are involved in this transformative work?

Ten intraprofessional teams have emerged from the work being done by the Transitions of Care team of 90 Days of Innovation: Ready Every Day, each with a separate area of focus.

Ten intraprofessional teams have emerged from the work being done by the Transitions of Care team of 90 Days of Innovation: Ready Every Day, each with a separate area of focus.

“The work touches so many points of the patient experience, from admission to discharge and many transitions in between,” says team lead Sandra Blevins. “Understanding the demand of our services is just as important as how we deliver them.”

The team, part of the 90 Days of Innovation: Ready Every Day initiative the Region is currently undertaking, has divided their work into two main sections; Demand Alignment and Capacity and Care Progression and Care Transitions. Within those two categories, 10 intraprofessional teams have emerged, each with a separate area of focus.

Under the Demand Alignment and Capacity Building umbrella, a team is working on a pilot program with the Cardiac Catheterization (cath) lab to facilitate more patients accessing their service.

“Currently, the demand for inpatient cath and Electophysiology Services is inconsistent day to day,” says Blevins. “Sometimes inpatient demand exceeds the daily inpatient cath capacity, which potentially results in delays in progression of care. With this pilot the cath lab is trialing, they will book two fewer outpatients during the week of May 11, which means they will still be doing the same number of procedures, just allocating two more spots a day to inpatients.”

There are also teams working within Medical Imaging, focused on MRI, Interventional Radiology, and Echocardiogram (Echo) services to help these areas better understand the demand for their services and the best way to improve the experience for their patients and clients.

A group of Internal Medicine physicians is working on aligning and leveling workloads for physicians and residents. This group is assisting with managing patient volume, and the geographic co-location of patients and physician consults.

“We’ve begun co-locating patients on our Clinical Teaching Unit (6200) with one of the resident teams there and we’re testing the process to see how it works,” says Blevins.

This is supporting the Community of Practice work also underway on Unit 6200, which is focused on an intraprofessional care model.  Both initiatives are supported by the co-location of the patient populations, reducing patients in off-service location, and the number of units the patients will be cared for.

Three other teams made up of physicians, clinical staff and leaders are working together to truly understand the demand, criteria and best practices for use of observation, telemetry and isolation beds.

Under the Care Progression and Care Transition umbrella, the work around transitioning to home hospital (also known as repatriation), is progressing with the help of a project lead and repatriation officer working in collaboration with physicians and staff within the Region.

“This group is also working  with two neighbouring health regions in addition to the provincial working group that is developing standards around transitioning to home hospitals throughout the province,” says Blevins.

The team working on the development and implementation of the stroke unit on 6300 is aiming for an improved patient experience and a shorter length of stay for patients who have had a stroke.

“Every patient who has had a stroke requires different care depending on their status, but if we can co-locate stroke patients in one area with resources dedicated to their care, we can improve the patient experience as well as their outcomes,” says Blevins.

All in all, approximately 50 people on 10 teams are working under the larger Transitions of Care team and that’s not counting all the employees and patients and families they talk to and receive information from. Each mini team consists of a mix of leaders, physicians, nursing and staff members, each with their own specialized knowledge and unique skill sets.

Patients and Families are being engaged in different ways – offering input into the work, participating in improvement events and providing ongoing feedback through interviews and surveys.

“We are working with a group of nursing staff who are, unfortunately, currently unable to perform their regular duties. Fortunately for us, they are coming to work each day to observe and report on many of our care processes,” Blevins said.

These staff members interview patients, observe work flows and gather and assess data and information to help these teams with their quality improvement efforts.

“Using the data they are collecting is critical to the work that we are doing,” says Blevins.  “It helps us align our improvement efforts to what will benefit the patients to the greatest degree possible. Having these staff available to offer their experience and enthusiasm has been one of the highlights of our work to date.”

Overall, the collaboration and enthusiasm for transformation these 10 teams have shown have truly changed and opened up the scope of work for the Transitions of Care team as a whole.

“Instead of a snapshot, we’re now seeing things in a panorama perspective and we’re thankful for all their hard work in improving our care and services for patients, clients and families,” Blevins says.

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