S.M.A.R.T.SM Discharge Protocol - Always Events - Picker Institute

S.M.A.R.T. SM
Discharge Protocol
ANNE ARUNDEL MEDICAL CENTER’S PLAN
FOR A SMART DISCHARGE- ALWAYS

Housekeeping
• Please silence or turn off cell phones
• Participants must attend the entire session to
receive MNA contact hours
• MNA certificates will be distributed as evaluations
are turned in at the end of the session
• This presentation is co-sponsored by Picker
Institute

SMART discharge video

Core Concepts of
Patient and Family Centered Care
RESPECT & DIGNITY: WE, AS PRACTITIONERS, LISTEN TO AND HONOR
PATIENT AND FAMILY PERSPECTIVES AND CHOICES.
INFORMATION SHARING: PRACTITIONERS COMMUNICATE AND SHARE
COMPLETE AND UNBIASED INFORMATION WITH
PATIENTS AND FAMILIES IN WAYS THAT ARE
AFFIRMING AND USEFUL.
PARTICIPATION: PATIENTS AND FAMILIES ARE EMPOWERED AND
SUPPORTED TO PARTICIPATE IN CARE AND DECISION
MAKING AT THE LEVEL THEY CHOOSE.
COLLABORATION: PATIENTS, FAMILIES, PRACTITIONERS, AND HEALTH
CARE LEADERS COLLABORATE IN THE ONGOING
DESIGN, DEVELOPMENT AND IMPLEMENTATION OF
POLICIES AND PROGRAMS.

MSU POP QUIZ
•How many patients were discharged from Jun-Aug 2011
855
•How many were seen in the ER
126
•How many were readmitted
125

MSU's % of "Always" Responses to the HCAHPS Question on Staff Telling What
New Medicines Were for Before Giving with options of Always, Usually,
Sometimes or Never
100.0%
90.0%
80.0%
% "Always" Responses
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan - Mar
2009
Apr - Jun
2009
July - Sep
2009
Oct - Dec
2009
Jan - Mar
2010
Apr - Jun
2010
July - Sep
2010
Oct - Dec
2010
Jan - Mar
2011
Apr - Jun
2011
MSU 81.3% 73.3% 70.4% 84.2% 75.0% 84.0% 73.7% 88.9% 62.5% 67.6%
MSU Benchmark 72.5% 72.5% 74.1% 74.1% 74.1% 74.1% 73.8% 73.8% 73.8% 73.8%

MSU's % of "Always" Responses to the HCAHPS Question on Staff Describing
Possible Side Effects of New Meds with options of Always, Usually,
Sometimes or Never
100.0%
90.0%
80.0%
% "Always" Responses
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan - Mar
2009
Apr - Jun
2009
July - Sep
2009
Oct - Dec
2009
Jan - Mar
2010
Apr - Jun
2010
July - Sep
2010
Oct - Dec
2010
Jan - Mar
2011
Apr - Jun
2011
MSU 38.5% 60.0% 50.0% 55.6% 36.4% 52.0% 52.6% 44.4% 25.0% 47.1%
MSU Benchmark 46.3% 46.3% 45.3% 45.3% 45.3% 45.3% 45.5% 45.5% 45.5% 45.5%

100.0%
MSU's % of "Always" Responses to the HCAHPS Question on Nurses Listening
Carefully, with options of Always, Usually, Sometimes or Never
90.0%
80.0%
% "Always" Responses
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan - Mar
2009
Apr - Jun
2009
July - Sep
2009
Oct - Dec
2009
Jan - Mar
2010
Apr - Jun
2010
July - Sep
2010
Oct - Dec
2010
Jan - Mar
2011
Apr - Jun
2011
MSU 80.0% 82.9% 76.7% 75.0% 72.0% 68.5% 74.3% 75.0% 79.2% 82.8%
MSU Benchmark 74.0% 74.0% 73.4% 73.4% 73.4% 73.4% 74.2% 74.2% 74.2% 74.2%

MSU's % of "Yes" Responses to HCAHPS Question on Talking to Patients About Help
After Discharge with options of Yes or No
100.0%
90.0%
% "Yes" Responses
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan - Mar
2009
Apr - Jun
2009
July - Sep
2009
Oct - Dec
2009
Jan - Mar
2010
Apr - Jun
2010
July - Sep
2010
Oct - Dec
2010
Jan - Mar
2011
Apr - Jun
2011
MSU 87.5% 80.0% 76.3% 75.0% 66.7% 88.6% 88.5% 89.5% 82.4% 95.7%
MSU Benchmark 78.9% 78.9% 80.1% 80.1% 80.1% 80.1% 79.9% 79.9% 79.9% 79.9%

MSU's % of "Yes" Responses to HCAHPS Question on Providing Written Discharge
Instructions with options of Yes or No
100.0%
90.0%
% "Yes" Responses
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan - Mar
2009
Apr - Jun
2009
July - Sep
2009
Oct - Dec
2009
Jan - Mar
2010
Apr - Jun
2010
July - Sep
2010
Oct - Dec
2010
Jan - Mar
2011
Apr - Jun
2011
MSU 87.0% 76.7% 83.8% 92.0% 88.9% 83.3% 76.0% 75.0% 100.0% 89.1%
MSU Benchmark 81.6% 81.6% 83.7% 83.7% 83.7% 83.7% 83.9% 83.9% 83.9% 83.9%

ALWAYS EVENTS TM
“By identifying the elements that should
always occur from the patient perspective,
then systems can be re-engineered to
ensure that they do, in fact, always
happen.”
-Tom James, MD

AAMC’s ALWAYS EVENT
100% of the time, 5 key areas will be
reviewed and discussed with the
patient and family prior to
discharge: Signs, Medications,
Appointments, Results, and Talk.

Why SMART SM
•Wave of the future
•Great acronym
•It works! Signs, Medications, Appointments,
Results, Talk

Pilot Study
•MSU only
•Start date: Dec 5 th , 2011
•4 months
•Want feedback- barriers, positive
experiences, etc
•Will introduce on 3 other units between
now and June 2012
•Goal: statewide, nationwide

S.M.A.R.T. Discharge Protocol
(SDP)
Admission:
Daily:
RN will educate patient and family on the “Be
Smart, Leave SMART”* worksheet and process.
RN and MD and Case Manager will review the SMART
worksheet with patients and families during bedside shift
report, rounds, physician visits, nursing assessment, etc.
Discharge:
RN will perform a “SMART stop” using the SMART
worksheet and AVS summary to ensure the 5 key
areas are addressed with the patient and family.
* “Be Smart, Leave SMART” worksheet will be referred to as the SMART worksheet throughout presentation

The Logistics
•Patients and families will be writing on the form
primarily
•SMART worksheet will NOT replace current
discharge instructions (AVS)
•AVS summary (i.e. discharge instructions) has
been revised to mirror SMART format
•Form will be kept at the bedside on a clipboard
•Extra forms kept in the alcove outside the room

SDP: Admission
RN will:
• Give SMART worksheet to patient/family upon admission to
room and write patient’s name at the top.
• Explain SMART acronym (see following slides)
• Tell patient and family to use this worksheet for
communication with their care team. They should write all
questions, comments, and notes related to their care on this
form, especially discharge-related.
• Explain the worksheet will be reviewed throughout
hospitalization and at discharge to make sure all critical
information is captured.
**All questions written on SMART worksheet will be
addressed by a clinician.

SDP: Daily
ALL Care Team providers:
Remind Patient & Family to:
• Take notes on worksheet when discharge-related material is
discussed
• Write down (non-urgent) questions to be discussed with RN,
MD or Case Manager prior to discharge
• Encourage additional comments/questions!
*If the patient/family are unavailable when MD/Case manager
rounds, answers to the patient’s questions on worksheet must be
relayed to the RN or written on the worksheet.

“S”
Signs I should look for and who I should call when I leave:
RN and MD will:
• Discuss critical signs that require medical attention once the person
leaves the facility. (i.e. temp >101, excessive bleeding, SOB, etc.)
• Differentiate which provider to call for the different signs (i.e, surgeon vs.
primary care)
• Point out the AskAAMC contact number on bottom of SMART worksheet
for questions once discharged.
Patient/Family will:
• Write these critical signs and provider information down on the SMART
worksheet

“M”
Medication notes:
RN and MD will:
• Discuss new meds, changed meds, stopped meds, side effects,
frequency and indications for use.
• Confirm accuracy of active med list* with patient and family
Patient/Family will:
• Write down what medication information is important to them- (i.e.
dosage, size/color descriptions, side effects, etc.)
• Write questions r/t medications.
• Who to call if they have questions post-discharge regarding
medications (i.e. primary care vs. surgeon).
• Review active med list* and confirm information with RN/MD.

Appointments I will go to:
“A”
Appointments already scheduled:
MD/Case Manager will:
• Inform patient/family of appointments scheduled for the patient postdischarge
(i.e. cardiologist, physical therapy, lab, etc)
• Ensure patient knows the phone number for the MD office.
Patient/family will:
• Write these appointments on the SMART worksheet.
• Inform MD/Case manager if patient is not able to make the scheduled
appointment (no ride, schedule conflict, etc).

Appointments I will go to:
“A” cont.
Appointments I need to schedule:
RN/MD will:
• Inform patient of necessary follow-up appointments
• Ensure patient knows what type of appointments need to be made
(cardiologist, physical therapy, wound center, etc.) and the phone
numbers.
• Review timeframe that appointments need to be scheduled.
Patient/Family will:
• Write information on SMART worksheet.
• Ask provider for office phone numbers they do not know.

“R”
Results for follow up:
(i.e. pending results that will not delay discharge)
RN/MD will:
• Inform patient and family member that certain results will not be available at
time of discharge (i.e. urine culture, pathology reports, etc.) , but they are still
able to leave.
• Instruct patient/family to write down these pending results on the SMART
worksheet.
• Instruct patient/family on which physician to call in order to discuss results
over the phone or at a f/u appointment.
Patient/Family will:
• Write pending results on SMART worksheet.
• Call physician or discuss pending results at a f/u visit.

“T”
Talk with me more about at least three things:
RN/MD will:
• Use this section as a conversation starter between the provider and the
patient/family.
• Address outstanding questions from the patient/family.
• Encourage patient to write down questions or areas of concern r/t
discharge.
Patient/Family will:
• Write down any questions about anything they are curious about.
(it can be more than 3)
• Ask RN/MD to answer their questions daily, so the information is given
prior to day of discharge.

**NEW LOOK
FOR THE AVS
SUMMARY***

SDP: Discharge…aka “SMART Stop”
MD will:
• Ensure that instructions and medications are correct on the AVS
when completing discharge navigator.
RN will:
• Ask patient if they need a new SMART worksheet to write notes
during the discharge discussion.
• Review all 5 sections of the SMART worksheet and AVS
simultaneously with patient/family to ensure critical information
has been noted. If something is missed, patient/family will be
instructed to write it down.
• Identify patient’s medication schedule on the AVS (AM, PM,
Bedtime, etc) and indicate last dose taken.
• Remind patient/ family that AAMC has a nurse available 24/7 to
answer questions post-discharge if unable to reach their
physician.
**ask AAMC 443-481-4000**

Now what
• Once SMART stop is performed, ask patient if we can have a
copy of their worksheet for process improvement purposes.
• If patient was unwilling/unable to complete, please collect form
and write the reason why it is blank on the front.
• Place copy of SMART worksheet in chart; whoever breaks it
down will place it in the SMART basket (near the d/c charts)
• We will count the number of SMART forms received and the
total number of discharges per day to monitor compliance.

Q & A