Early Discharged Home Care Program Nursing Essay

Title: The report of a pilot Integrated Care Pathway named “Early Discharged Home Care Program for Breast Cancer Patients after Surgery” in 2010.

Introduction:

Hospital Authority (HA) plays the major role and responsibilities in public health care service. The arising demand and expectation of public health service drive HA to strive for more safe and efficient performance in health services. Therefore, Hospital Authority (2010:3) decides to set up “the service directions and strategies for addressing the challenges in terms of demand management, quality and safety” in 2010-2011 HA strategic service plan. Hospital Authority (2010:18) promises to “redesign work to streamline work process and foster new ways of working to streamline work process and enhance efficiency.” In addition, HA implements Lean Management Training for executives, managers and advanced practice nurses to build up competence in effective management and leadership.

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In this retrospective report, I would like share the experience of operation a new service by coordination with other departments in direction of HA planning. I will illustrate the important of operations management to enhance services quality, effectiveness and efficacy in providing new health care service clinically. I will focus on the part of post mastectomy home care in an Integrated Care Pathway named “Early Discharged Home Care Program for Breast Cancer Patients after Surgery” in 2010. As an advanced practice nurse in Community Nursing Service, I had both the management and leadership roles to lead our teams to accomplish this new service objectives and operations. At the beginning of this program, we found some barriers and challenges in condition of restrained resource. Some nursing staffs felt this new service as extra workload with low morale and motivation, and some nursing staffs verbalized their feeling of lacking confidence in caring of patient after mastectomy with drain care. Zeytinoglu et al (2007) show that nurses’ turnover intentions are associated directly to nurses’ perception to daunting work environment with heavy workload and low job satisfaction. Day et al (2006) also describe excessive workload which is one of the extrinsic factors dominate and reduce nursing staffs morale. Hospital managers should be responsible for nurse retention strategies and the creation of healthy work environments for nurses (Andrews 2005). In addition to operating the new service, both the management of increased workload and internal risks of low moral were also essential to be managed at the time.

The purpose of this report is to present and discuss the development of a pilot integrated care program for improvement of healthcare by applying management theories and skills. The theories and strategies of operations management and lean were applied to overcome challenges and create a facilitative environment in order to maintain quality and efficacy to addressing the development of new service in our department. At first, the current problems and bottleneck were indentified in process map. The analysis of internal and external environments was discussed with tools of PSTLE and SWOT. After analysis, the process of strategic management and transformation process with lean management will be discussed. Then the service outcome will be reported for continuous monitoring and evaluation with comment and recommendation. Finally, I will draw a conclusion to summarize and prove that how operations management can improve the quality and efficacy in development and operation of new services.

Background:

Rode et al (2007) estimate that more than 1.2 million women worldwide are diagnosed with breast cancer yearly. Parkin and Fernandez (2006) explain the incidence rates of breast cancer have been increasing globally due to the lifestyle changes such as obesity, lack of exercises, decreased childbearing and breast-feeding; and also related to increasing exposures in risk factors including increased exogenous hormone exposure and detrimental dietary. In Hong Kong, the numbers of new cases of breast cancer in female have been raised from 1918 in 2000 to 2962 in 2009 (HA 2011b). As a result, the demand for surgical treatment and post-mastectomy care for breast cancer patients are increasing in HA hospitals. Therefore, HA necessitated to increase in service capacity to meet the growing demand; and HA reinforced the integrated cancer care by coordination and streamline of breast cancer patients with their treatment journey from the in-patient and post-discharge phases.

As a team in HA, different department managers collaborated to attain the above objectives in our hospital as set up in HA annual plan. Hospital Authority (2011a:8) supports “frontline professionals to present clinical programs that are in line with the Strategic Service Plan.” Stroupe (2012) also encourages health administers and frontline care providers collaborate in service design to improve services which are affordable and sustainable in this challenge era. This breast cancer integrated care model was a pilot program in our hospital. It was led by surgical department and supported by our community nursing (CNS) department for the phase of out-patient care. The process mapping of conventional and pilot program were compared (Diagram 1); all stockholders identified and agreed the major bottleneck in conventional process flow was the practice of finish with drain and stitches off in ward; this traditional practice hindered patient discharge. This problem prolonged patient’s length of hospital stay and wasted hospital bed capacity. Eventually, HA bore higher cost for this prolonged in-hospital care.

Pre-operation investigation, e.g. physical examination, vital signs, radiological examination, blood samples, consent

Admission:

Breast cancer patients admit for operation as scheduled

Anesthesia consultation

Operation

Pre and Post mastectomy care information and education by nurse and physiotherapist

Post-operation (acute care): monitoring and prevent complications

Post-operation (sub-acute care): wound dressing, drain care, Off drain: until drainage = or < 30cc for 2 consecutive days, off stitches on D10

physiotherapy

Patient Discharge:

Stable condition

Follow up in Specialist Outpatient Department (SOPD)

Day 1-2

Day 2

Day 2

Day 3

Day 3-4

Day 4-14

Day 10-14

Conventional Breast Cancer Operation Treatment

New Pilot Program

Early Discharged Home Care Program for Breast Cancer Patients after Surgery

Admission:

Breast cancer patients admit for operation as scheduled

Pre-operation investigation, e.g. physical examination, vital signs, radiological examination, blood samples, consent

Anesthesia consultation

Day 2

Pre and Post mastectomy care information and education by nurse and physiotherapist

Day 2

Operation

Day 3

Post-operation (acute care): monitoring and prevent complications

Day 3-4

Post-operation (sub-acute care): wound dressing, drain care

physiotherapy

Day 4-7

Patient Discharge:

Stable condition

Follow up in SOPD

CNS provide home care:

Wound & drain care, off stitches on D10

Off drain: until drainage = or < 30cc for 2 consecutive days

Day 7 610-14

Day 1-2

Major bottleneck

Solution

Diagram 1 – Breast Cancer Patient with Surgical Treatment & Care Logistic Chart

Aims and objectives:

Dahlgaard et al (2011) emphasize that the importance of identification and understanding of end users needs and priority are crucial in the change process of provision of a new service. Pettersen (2009) also emphasizes that the focus of internal and external customers’ needs and expectations are essential for successful service improvement in total quality management. The aims and SMART objectives of this pilot service are set up to direct the service improvement.

Aims:

1 To facilitate breast cancer patient to maintain high quality of life and the patients are well supported by integrated care with multiple health disciplinary coordination in patient treatment journey seamless from hospital to home care phase.

2 To provide a continuum of specialized care for post operative breast cancer patients in home care phase by Community Nursing Service.

Objectives:

1. To Implement interventions and streamline breast cancer pathway on April 2010.

2. To shorten patients’ length of hospitalization = or > two days.

3. To reduce hospitalization cost = or > two days hospitalization cost per patient.

According to Slack et al (2010), there are five operational performance objectives for operation system: cost, quality, speed, dependability and flexibility. The operational performance objectives are realized from the perspective of services customer needs and expectations. Quality is recognized as top priority among the performance objectives for all customers concerning to patient’s life, provided services, treatment and care in this service. The level of priority with customers and performance objectives were ascertained (Table 1). It is important to understand and address clearly what are the customers’ preferences and needs in customer services and marketing (Kotler and Keller 2006). It is the hallmark of effective operation management to match the operations performance objectives to achieve the customers’ satisfaction with customer requirements. (Barnes 2008).

Customer

Higher priority Lower priorityPerformance Objective

Patient

Quality

Dependability

Flexibility

Speed

Cost

Surgery

Quality

Dependability

Flexibility

Speed

Cost

Hospital stockholder

Quality

Dependability

Cost

Speed

Flexibility

Table 1: Performance objectives with level of priority.

Analysis:

Today health care service sector is complex with multi-faceted challenges among political influences, current economic perspective, social preferences, technology development and organization systemic barriers (Hutubessy et al 2003). These pressures are not only distributed to administers; and across the entire level of health sector. PESTLE is a systematic analysis tool to evaluate the external environment with actual and potential impact on our services and organizations. PESTLE stands for Political, Economic, Sociological, Technological, Legislate and Ecological. Daft and Lane (2010) advise organization managers to be sensitive to external environment factors, because the constant change and evolution of environment will create uncertainty to organization especially in a state of lacking updated information. The PESTLE analysis facilitated our teams to review our roles, values and status. It provided us information to determinate the opportunities and constrains which were concerned in our service planning. As a result, we could justify and balance the internal and external customers’ needs strategically and accordingly in real time.

PESTLE:

The detail analysis of external environment for our pilot service was given in PESTLE format.

Political: In Hong Kong, the demand on quality and efficacy of health care service from public is now generally higher than before (Leung and Shone 2006). HA acts as an accountable public health service provider, HA has to secure public’s trust and meet the public expectations. Naylor (2002) explains that the ongoing change in environments and needs from social impose organization to adjust its objectives to meet customers’ expectations. Therefore Hospital Authority (2010:2) declares that “we are committed to reducing the waiting time for cancer surgeries”. HA (2011a) responses continuously to manage growing service demand by reconfiguring services to prevent avoidable hospitalization and shorten length of hospitalization.

Economic: The consideration of economic cost in the evaluation of public health service has been heighted in health policy and planning increasingly (Hutubessy et al 2003). Hospital Authority (2011a:34) “adopt strategies and systems to maintain financial sustainability”. Specifically, HA supports hospital administrators to implement innovated and incentive model or program to promote productivity and quality in services in order to enhance the cost effectiveness. Edejer et al (2003) suggest the exploration of new strategic interventions in view of cost-effectiveness analysis (CEA) can determine current practice cost-effectiveness, optimize resources utilization and maximize health service quality and capacity. The aims and objectives of this pilot service were emphasized on both of the quality of patient’s life and efficacy of health service in a win-win approach. This approach fulfilled the basic premise of HA in providing essential, safety, quality and effective healthcare services to Hong Kong residents.

Sociological: In Hong Kong, an increasing incidence of breast cancer has been observed as local women have been prone to the westernized lifestyle over the past decade (Wong et al 2007). Department of Health (2011) reports that the breast cancer surpassed lung cancer to the third most common cancer among females in Hong Kong since 1990. The burden of breast cancer is likely to increase due an increasing in population, life expectancy and ageing population in the future. The average life expectancy for local females and males are 85.9 yrs and 80 yrs respectively in 2010 (Department of Health 2011). Our service area with catchment populations are 1,036,227 in overall Hong Kong populations of 6,861,280 (Hospital Authority 2009). The demographic characteristics are mixed with residential town and remote villages populations (Picture 1).

Picture 1: Extend service area with town and remote villages.

Technological: Today, the medical and scientific technologies are fast advancing; and this is an opportunity for the health care. Wyatt et al (2004) reports home nursing interventions are effective to facilitate and support breast cancer early discharge following breast surgery in sub-acute stage, and specific nursing protocol is suggested to be cost effective to promote patient care knowledge and outcome. Hospital Authority (2009) encourages continuous service improvement through advanced technology and treatment options with evidenced base for efficacy and cost-benefits to keep up better services. HA developed the third generation of the Clinical Management System (CMS III) to enhance use of information technology in clinical system that support health care management. In previous practice, community outreaching nurses can only take public transport for home visit care. The disadvantage was wasting time in journey and waiting for public transport especially in remote area (Picture 1). For this new service delivery, hospital administers supported community outreaching nurse to shorten traveling journey and time through hiring a taxi for of home visits. As a result, the alternative transportation strategy saved transportation time for more nursing care delivery.

Legislate:

The increasing public health service demand has brought profound impact on HA. Hospital Authority (2009:6) regards to the principle as stated in the HA Ordinance that “no person should be prevented, through lack of means, from obtaining adequate medical treatment.” Therefore, it is imperative for HA to face the challenge of growing service demand and ensuring service quality and safety. In nursing, we are guided to delivery safe and competent nursing care with global standard of practice by the Professional Conduct for Nurses in Hong Kong.

Ecological:

Clinical waste is potentially dangerous when it contains infectious materials and sharps. Therefore, it is important for health professionals to comply special caution in the handling and management of clinical waste with the legal requirements as stated in the Waste Disposal Ordinance (Cap. 354). It aims to protect public health; and minimize risk of pollution to the environment.

SWOT:

SWOT analysis was also carried out to assess our strengths, weaknesses, opportunities and threats internally and externally. Swage (2004) describes that SWOT is an effective tool for internal scrutiny and identification of the internal with strengths and weaknesses; as well as the external factors of opportunities and threats related to the organizations. For quality service improvement, the challenges and opportunities of internal and external environment in a health care organization can be analyzed by SWOT (Schulz and Johnson 2003). SWOT outlined a clear picture for identification and analysis of the environments around the current circumstance to necessitate a strategic action plan for our new service.

In this SWOT analysis (Table 2), the pros and cons of existing system facing new service were determinate for our organization. SWOT was also adopted for internal assessing and diagnosing in our organization. It helped us to identify and remedy the unfavorable factors early; and to evaluate our ability and capacity to overcome the challenges and difficulties.

Internal factors

Strengths:

Well existing community nursing service network with 8 service centers located in service area.

Experience community nursing workforce.

Managers experienced in running new services and programs.

Exiting effective communication system and channels.

Hospital administrators provided well support in information technology and resources especially in transportation.

Weaknesses:

No extra manpower, some frontline staffs may be exhausted due to increased workload.

Some nursing staffs felt this new service as extra workload.

Some nursing staffs had low morale.

Some junior nursing staffs were lack of confidence.

Spent more time for training, monitoring and evaluation in new service.

External factors

Opportunities

Build up new network and collaboration with other departments; a good milestone for other service development in future.

Improving health care service quality, capacity and efficacy.

Reducing hospital service cost.

Increasing hospital and department reputation.

Staff promotion for good performance in new service.

Threats

Existing service may be affected especially at the beginning of new service.

Some staffs may be over stress and cause turnover if the stress is not managed well.

Parked off conflicts among department managers in bargaining service capacity and objectives.

Table 2: SWOT analysis in our organizations.

Theoretical framework:

Lean is a production practice to create or add more value for customers that considers by eliminating wasteful activities or procedures, and preserving value with less work (Baines el al 2006). Brandao (2009:122) defines lean as “an improvement approach that consists in eliminating waste (steps that do not add value to the customer/patient, e.g. interruptions, delays, mistakes…) to improve the flow of patients, information or goods.” The lean management was applied as a framework to guide our team in this pilot service development and implementation. We were going to improve the efficacy of breast cancer care by streamlining the patient pathway with recreation an effective flow in health care. This process did not consist in only exercises of reduction in length of hospital stay and cost. Meanwhile, the quality of care and patient safety both must not be compromised in the transformation. Kollberg et al (2006) supports that lean thinking and initiatives are applicable in health care settings to overcome exciting care problems and barriers. Bozena (2010) reports in a literature review that lean management is one of the effective improvement approach in health care system. According to (Pettersen 2009) lean production consist of five main general principles of (1) just in time practices, (2) resource reduction, (3) improvement strategies, (4) standardization and (5) scienti¬c management. We complied with the above principles to maximize our productivity and eliminating the wastes. Lighter (2011:232) states “Producing greater value with less work is the underlying tenet of lean process management.”

(1) Just in time practices by following the flow in map process logistic and integrated care pathway.

(2) Resource reduction by eliminating the bottleneck and minimizing nurse wasting time in waiting public transportation during home visit journey.

(3) Improvement strategies by effective communication and collaboration, providing training, resources management, continuous monitoring and evaluation.

(4) Standardization by setting up integrated care pathway and nursing procedure guidelines and protocol.

(5) Scienti¬c management by operations management with lean and supported by up-to date research support.

Nankrvis (2005) emphasizes that operations management is a significant component among marketing, finance, operation and human resource management in all organizations. Bamford and Forrester (2010) describe that operations management is focused in the design, planning and control of resources for competent products or services. Naylor (2002) explains the importance of operations management to support organization to find right strategies for investing in and making products or services to meet customers’ demand by effective and efficacy ways in a current competitive and challenging environment. By this opportunity, we applied operations management with lean to lead the transformation of this pilot program. With help of the effective management strategy and updated research support, concerned administrator and managers collaborated to work out the design, logistic, workflow and implementation according to professional standards and outcome criteria as agreed by all managers to ensure the quality of services up to national standard. Berwick et al (2008) describe that conscientious managers would peruse to provide high quality services that are reliable and supported by up-to-date evidence-based. In addition, we had to continuous monitoring and evaluation the workflow including resource, staffs performance, customer satisfaction and outcome in new service to ensure that it was running in tract to justify the objectives. Slack et al (2010) emphasize that the balancing of capacity, demand, customer satisfaction and cost effectiveness are fundamental of operations management.

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Transformation process:

Naylor (2002) explains operations management is a managerial system to perform, change and control from a variety of resources in order to produce products or services to satisfy customers’ needs by effective transformation process. In our new service, the three components of inputs, transformation processes and outputs were summarized (Table 3). All our managers contributed to operate and transform a range of resource inputs into a range of desired outputs through operations management with efforts of training, coordination, team work. Harrison (1996) points out those operation managers have both role and responsibility in carrying out service design, planning, workflow and implementation with control and lean operations. The various inputs with different elements that together make up the transformation process are diverse in nature. The managers had to face different challenges of human resource management, customers demand, professional knowledge, service design, planning, operation and control. Nankervis (2005) describes effective operations management can facilitates the transformation process in activities of resource distribution, movement or transportation of products or people, information, knowledge and experience.

Inputs

Transformation processes

Outputs

Breast cancer patients demand.

Workforce from administrators, managers, surgeons, nurses, multiple health professional disciplinarians, frontline staffs.

Investment of time, resources, equipment, information, technology and finance.

Maintained collaboration among managers with regular meeting.

Surgical department set up wound and drain care protocol and provide specific nursing care training which enhance nursing staffs’ confidence.

Department mangers provided update training, guideline and support for staffs timely.

Community nursing service provides breast cancer care and rehabilitation at home phase.

Effective communication to allow feedback and monitoring in pilot service progress by regular operation meeting and ad hoc advice support from team coordinator.

Setting up integrated care pathway

Setting up the map process and logistic of patient flow from in-hospital phase to home care phase.

Enhance in home care phase to improve patient quality of life.

Setting contingency plans for variation.

Some nursing staffs with low morale.

Some junior nurses were lack of confidence.

Provided resource support to frontlines for reliving workload and stress, e.g. hiring taxi for visit journey.

Expressed recognition and empowerment to staffs when they had made a good effort and performance.

Regular operational meeting with frontlines and encourage bottom-up communication.

Table 3: The transformation process with inputs and outputs.

Preliminary report:

This service outcome and performance was reported for continuous monitoring and evaluation with comment and recommendation. The outcome and data from April 2010 to April 2011was summarized.

The total number of breast cancer patients was early discharged with home care: 156

The average length of hospitalization in early discharged program: 7.3 day

The average number of shorten days of hospitalization per patient: 3.9

The cost per inpatient services per day in HA hospital: $3590 (Hospital Authority 2010).

The expenditure of hiring taxi for transportation in home visit journey: $468,340

The saved cost = (A) x (C) x (D) – (E) = $1,715,816

Histogram 1: Length of hospitalization

.

Recommendation:

Hospital administrator, managers and frontlines should collaborate to implement quality improvement strategies through both top-down and bottom-up communication in regular quality meeting every three months before June 2012.

The most significant and imperative problems, as well as customers’ demands according to performance objectives should be stated out for setting priority of response and improvement before June 2012.

Managers and senior staffs should accomplish leadership and management training course as provided by HA before March 2014.

Keep continuous service subsequence monthly reporting and monitoring in 2012.

Risks:

In prime principle, the quality of existing services should not be compromised. The arrangement of training and meeting should be well planned to minimize affection on daily operation. Nurses will be frustrated and burnt out in daunting working environment of heavy workload and lack of support simultaneously. Therefore managers should consider both negative and positive feedbacks from frontline conscientiously, because the long term of low morale, dissatisfaction and exhaustion will induce nurses’ turnover. Sellgren et al (2009) report that the negative impacts of stressful workload and poor leadership are accountable for high nursing turnover rate. Therefore, the supervisors should optimize a working environment for frontline staffs with support and recognition. O’Brien-Pallas et al (2006) suggest to create a healthy work environment for nurses in order to reduce nurse turnover.

Conclusion:

HA is facing the impact of increasing service demand and higher expectation from public. Hospital Authority (2011a) responses continuously to manage the growing service demand by nurturing leaders with management training, supporting of redesign work flow to streamline process and enhance efficiency. The collaboration of different departments can maximize synergy effects on development of integrate care pathway. Health care services are complex; the safety and quality are utmost paradigm in health care professional. A successful complement of high standard operation of health service needs both effective leaders and management strategies. Beech and Vissers (2005) describe operations management is an effective framework for health organization in planning, control, and transformation of inputs into desired outcome towards committed missions. Graban (2011) suggests hospital leaders to apply lean that is essential for a competitive and cost effective advantage to improve service quality and productivity especially in constrain of resource.

Firstly, we have to aware and identify an operational problem such bottlenecks and wastes in our department or hospital. Health managers can apply both operations management and lean theories, in addition with PESTLE and SWOT to analysis the exciting internal and external environments. Leaders should apply learned leadership skill to lead people with heart, and mangers should lean services with sound management knowledge to chase organization goals. Finally, I would like to summarize that the application of operations management and lean with analysis tools can facilitate to improve the quality and efficacy in running new services successfully.