- Email: [email protected]
Creating an Obstetric Preadmission and Discharge Clinic: Saving Time, Saving Money and Increasing Satisfaction
Creating an Obstetric Preadmission and Discharge Clinic Saving Time, Saving Money and Increasing Satisfaction
Tammy Smith, MSN, RNC-ob Renece Waller-Wise, MSN, CNS, CLC, LCCE, CNL
Staff of the Family Birth Center at Southeast Alabama Medical Center (SAMC) in Dothan, AL, reviewed the literature to study best practice in patient education, Centering Pregnancy and promoting family-centered care environments. As a result, we developed an obstetric preadmission and discharge clinic. The focus of the preadmission clinic and group-format discharge class bought patients into a setting where consistent education is completed in a relaxed and controlled environment. The overall experience results in positive outcomes for patients and the hospital. This is the story of how we did it.
®
About Our Facility SAMC is a 420-bed not-for-profit regional referral center serving 600,000 residents in our geographic area. The Family Birth Center at SAMC offers a state-of-the-art facility with a familycentered approach to care, where more than 1,700 newborns are born annually in 27 labor-delivery-recovery-postpartum (LDRP) rooms. The Family Birth Center includes a Special Care Nursery (Level II) and a five-bed Maternity Evaluation (triage) unit. The primary language of the patients giving birth is English, with approximately 5 percent speaking Spanish as their primary language. Most recent data show a payer mix of 39.8 percent from private insurance. Medicaid payment accounts for 57.7 percent, including payments from Florida and
• Staff at the Family Birth
Bottom Line
Center realized that their preadmission and discharge processes could be improved.
• Collaboration among a variety of departments ensured successful change.
• Streamlined processes have resulted in increased
patient and provider satisfaction and cost savings.
Georgia. One percent of payment comes from Medicare, and 1.5 percent is private pay. A review of the statistics from the childbirth education department revealed a declining trend in childbirth class attendance. Fewer patients were attending prenatal classes, averaging only 19 percent of the primapara patient population. The goal of the department was to have 50 percent of first-time mothers Tammy Smith, MSN, RNC-OB, is the director of the Women’s Center at Southeast Alabama Medical Center in Dothan, AL; Renece WallerWise, MSN, CNS, CLC, LCCE, CNL, is a licensed perinatal clinical nurse specialist at Southeast Alabama Medical Center and an adjunct faculty member at Troy University in Troy, AL. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2011.01620.x
120
© 2011, AWHONN
attend class. Sadly, we discovered that we were not unique, with only one-third of expectant parents participating in classes nationwide (Berman, 2006). Changes in hospital reimbursement from insurance companies had placed a greater emphasis on outcome measures. We identified that many of these measures could be achieved through improvements to patient education. There was greater recognition of the importance of health education and its ability to assist in the economic goal of reducing high costs in health care. We knew that there are costs associated with developing any educational program, but we believed the cost benefit occurs when patient satisfaction increases and a lifelong relationship is established. To control costs and to realize cost savings, cost benefits or cost recovery, hospitals must develop ways to deliver patient education more economically (Bastable, 2006). Thus, the staff of the Family Birth Center at SAMC began with an original plan related to the educational needs of our patients. We reviewed best practices and evidence-based literature in an attempt to draw conclusions regarding our current practice, so that changes that could be made. A summary of the literature review follows.
Reviewing the Literature As far back as 1993, the Joint Commission recognized the importance of patient education by nurses and began establishing nursing standards for patient education. Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered. Providers must also consider the literacy level, education level and language skills of every patient during the education process. Educating the patient will increase the competence and the ability for patients to manage their care independently. There are many benefits to patient education (see Box 1). When educating a pregnant woman, including her significant other and/or family can build a larger support system for her, and motivate all involved to promote learning (Bastable, 2006). One research study we reviewed presented information on a new model of prenatal care and education. This model was based on a client-centered focus and was designed to empower the pregnant woman. This approach used group discussions to augment prenatal care during the final months of pregnancy and early months of postpartum. Group sessions are conducted in a circle to promote trust and authenticity. This circle supports socialization and moves the leader into the group as a member instead of authority figure. Participants socialize and enjoy healthful snacks while learning important information about caring for themselves and their newborns. This model of care has a positive outcome on pregnancy because of the positive influences that social support systems have for the expecting mother (Reid, 2007). Nurses often have insufficient time before discharge to fully address the concerns of new mothers and the potential prob-
http://nwh.awhonn.org
Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered of women’s childbearing experience. In light of these survey results, the reality of decreased hospital stays for postpartum families means it’s increasingly important that an educational plan including nontraditional approaches be tailored to meet the specific needs of each family.
Processes Prior to Change
lems that can occur after discharge. For new parents, the postpartum period can be emotional and is often a time of stress, change and sometimes crises. There is research that attempts to determine what learning topics are the most important to mothers. Studies indicate that the most important teaching priorities for postpartum mothers are related to postpartum complications and newborn care, with feeding the baby at the top of the list (Birk, 1996; Bowman, 2005). According to Todd (2004), a needs assessment should be conducted when initiating any education of new mothers. Asking questions that can determine the most important educational needs, as well as evaluating the patient’s pain and emotional status, will help determine if learning can occur. It will also help establish a bond between the mother and the caregiver. Todd also explains that it’s important to educate members of the patient’s support system, as well. Another study we reviewed focused on the benefits of group classes during the postpartum period and discusses the importance of empowerment. The Nursing Theory Workgroup (1990) proposed broadly that empowerment should include the practice of nurses assisting clients to recognize their own strengths, make their own decisions and be independent and self-reliant (Aston, 2002). Finally, today the care of the childbearing family requires the provision of information and support within the constraints of cost containment and shortened length of stay while meeting the needs of culturally diverse families. Declercq, Sakala, Corry, and Applebaum (2007) conducted the second national survey
April
May 2011
Although the labor experience is an exciting time for families, it can be a difficult time as well. The response to pain as well as trying to care for a newborn can be overwhelming. This reaction can inhibit the ability to learn and retain information taught during the intrapartum and postpartum course. Patient satisfaction surveys at our hospital revealed a need to improve the admission, discharge and teaching methods. To identify areas in which patients perceived a need for improvement, we reviewed the Press Ganey database to look at trends in patient satisfaction ratings. Patients reported dissatisfaction with the admission process. We reviewed specific questions from the Press Ganey Survey related to the speed of admission, courtesy of person admitting, preadmission process, explanations of test and treatments and information provided to family related
box 1
Benefits of Patient Education • Increases patient satisfaction • Improves quality of life • Improves continuity of care • Decreases patient anxiety • Effectively reduces patient complications and incidence of disease • Promotes the adherence to treatment plans • Energizes and empowers patients to become actively involved in their plan of care
Nursing for Women’s Health
121
to conditions and treatments. We also reviewed Press Ganey questions related to discharge. Specifically we looked at extent they felt ready for discharge, speed of discharge, instructions for care at home and explanation concerning baby needs (see Box 2). Due to the low patient satisfaction ratings in this area, we placed a particular focus on this in our work. We began to review our processes of education from admission to discharge and discovered that there were more processes that could be included in our project. Physicians complained that there was a delay in preparing inductions and a delay in surgery start times in the morning upon the patient’s arrival. Inconsistencies were found in the patient registration process. Some patients were registered in the emergency room while others were admitted in the birthing unit. The combined admission history and physical exam, consenting process, blood work and education averaged approximately 1 hour or more to complete. This delayed the nurse’s ability to initiate the induction of labor or prepare the patient for surgery in a timely manner. This limited amount of time also burdened the nurse to complete a large amount of work in a very short time frame. Nurses who worked the night shift often had to stay past the end of their shifts to complete work due to the patient’s arrival time. The nurse was not able to complete adequate education before the start of the patient’s labor. The information was typically rushed and the patients were not given time to ask questions. The birthing unit’s employee satisfaction surveys revealed that nurses were dissatisfied due to the inability to complete
quality work in a timely manner. Many nurses experienced delays in charting due to the increased amount of tasks involved with discharging a mother-baby dyad. Much of the education that could have been initiated on admission was not started until discharge. This bottlenecking resulted in an increase in overtime hours due to the nurse staying after the shift to complete charting. The unit’s overtime percentage for salary was above the target. In light of these issues, members of the unit began to research information to find ways to improve each of these areas in addition to our education changes. The process previously in place required patients scheduled for cesarean surgical deliveries to attend a preanesthesia clinic scheduled through the surgery department. During this appointment preanesthesia nursing assessment and surgical consent forms were initiated before the admission day of surgery. Upon admission to the birthing unit, the labor nurse completed a seemingly duplicate nursing admission assessment and unitspecific consent forms, drew blood for lab work and began the initial intrapartum education.
Planning and Preparing for Change After our literature review, which took approximately 3 months to complete, we found that evidence-based practice suggested that improvements could be made to the admission process and teaching methods. A practice change was evaluated to streamline the admission process and individualize teaching methods for patients scheduled for induction of labor and for cesarean
box 2
Press Ganey™ Patient Satisfaction Scores
122
Admission
Before Implementation (Year to Date 2005)
After Implementation (1 Year Later 2006)
(mean scores)
85.7
92.9
Speed of admission Courtesy of person admitting Preadmission process Explanations happen during tests and treatment Info family re: condition/treatment
83.9 92.9 80.0
91.1 95.8 92.2
90.9 87.5
91.7 95.1
Discharge
Before Implementation
After Implementation
(mean scores)
86.2
90.0
Extent felt ready for discharge Speed of discharge Instructions care at home Explanation concerning baby care
86.2 71.4 93.7 92.1
93.7 83.2 94.6 94.6
Nursing for Women’s Health
Volume 15
Issue 2
Involvement of all departments in changing practices ensured the success of the project deliveries. Group teaching was evaluated to streamline discharge teaching for postpartum mothers and establish a comfortable supportive environment more conducive to learning. At this point, the process of establishing a preadmission clinic and discharge class for the birthing unit began. Preparation to initiate the preadmission clinic took place 6 months before the opening of the clinic, during which time meetings were held with ancillary departments to revise processes and implement the new practice change. Involvement of all departments in changing practices ensured the success of the project.
Registration One goal was to streamline the registration process; therefore, meetings were held with this department. Previously, the patient presented in one area of the hospital to be registered and was taken to another area for treatment. Many times patients were lost within the facility. Changes to the registration process included converting an existing unit secretary position to a registration representative who would register the patients directly on the unit. This person would be able to issue a preregistration number for the mother and the newborn as well as have the patient sign forms to initiate treatment for both mother and newborn during her appointment time. The implementation of the registration representative also allowed insurance information and billing to be obtained during the preadmission process. Patients requiring precertifications for insurance, copayments and filing of Medicaid letters could be handled during this process.
Laboratory Laboratory was the second department involved in the practice change. Previously, labs were drawn either in preanesthesia clinic or on admission, which slowed the process of preparing the patient for induction of labor and/or surgery. Meetings with laboratory took place to determine the feasibility of drawing and running lab samples on Friday for a scheduled surgery on Monday. These meetings included consent from all obstetricians, anesthesiologists and pathologists to complete a complete blood count as well as a Type and Screen for surgery for these patients in advance of induction or surgery date. Plans also involved establishing a mechanism for blood samples to be obtained and analyzed in this new outpatient setting. This included a mechanism for identifying the patient at the time of the preadmission appointment with an armband that would remain in place until and including hospital admis-
April
May 2011
sion. This process also included a protocol for patients who refused to wear an armband until admission and for those who returned for admission without the armband. Potential time savings were identified at this point with respect to how blood work was completed by the laboratory. Under the old system, all lab work was completed as a “stat” specimen on the day of admission so that results would be available before the start of the procedure. Under the new system lab work would be run as “routine” during the preadmit visit. Serendipitously, this allowed the laboratory department to focus on more critical lab draws and resulting during the high volume times of early morning.
Preanesthesia A meeting was then held with the existing preanesthesia clinic and we determined which parts of the patient record were duplicated. It was decided that all surgery paperwork normally completed at the preanesthesia clinic would be completed during the new obstetric preadmission appointment. For convenience of the patient, the obstetric preadmission clinic would now be the only appointment the patient would have to attend. Meetings were held with anesthesia personnel, social workers and case management, along with lactation services. These meetings involved a mechanism to trigger consults with these departments when patient problems were identified during the preadmission process. This would prevent late discovery of a patient’s complications. For example, identification of a patient who may not be a candidate for an epidural or may need assistance for an early detection of a breastfeeding complication might be discovered during the preadmission visit. A process was established to refer patients who warrant consults with these issues.
Other Departments Meetings were held with the printing department to develop appointment cards with instructions on appointment date and time as well as directions to the clinic. A process for scheduling of patient appointments for the clinic and utilization of the appointment card was then determined. Networking with the systems manager for the computerized labor documentation system assisted us in the process for documentation. A new screen in the documentation system was then created to use during our preadmission appointment. This screen would include the nursing assessment, lab work, consent information and all education to be taught during the
Nursing for Women’s Health
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clinic visit. The forms could be printed and placed with the mother’s and baby’s chart for the labor nurse to view on admission. On admission, the labor nurse would only need to complete the physical assessment, initiate intravenous access and initiate fetal monitoring.
Childbirth Education Conferences were then conducted with the childbirth education department to involve our educators in determining what patient education was to be completed and what teaching methods were to be used during the preadmission appointment. Ultimately, it was decided that the preadmission clinic would be staffed from the childbirth education department, and a position was created for a designated nurse. This position was created by moving a staff nurse full-time equivalent from the birthing unit to the childbirth education department. This decision was based on the best practice idea that offering consistent teaching methods would improve the overall patient experience and learning atmosphere. Once this process was established, educational meetings took place with all staff located on the unit, as well as admitting obstetrician offices, to inform and educate these groups as to the change in process for patients with scheduled procedures.
Implementing Change The first phase of this process change—the establishment of the preadmission clinic—was in place for approximately 6 months while we evaluated the flow of the process. Minor changes were made to the process, including the physical location of the clinic. This 6-month time frame also allowed the Family Birth Center staff and ancillary services to become accustomed to the new process before initiating the next phase of the change. The second phase of the process change was to implement a class setting in which the same preadmit nurse could complete appropriate postpartum and newborn care teaching before discharge. We then began working on what information should be included in the class, teaching methods used and time frame for the class to occur. A group setting with a circular seating arrangement was decided upon based on the Centering Pregnancy approach to promote a comfortable environment that fosters socialization. The class would be called “Mom and Me Tea.” Cookies and tea would be offered to promote a relaxed environment, and it was sometimes referred to by the nickname “Tea and Teach.” The class was scheduled for 10:30 a.m. each morning before the normal discharge time of families. Multiple teaching methods are used, including videos, handouts and verbal instruction. The fathers and other support persons are encouraged to attend the class to foster support for the new mom, and teach them how to care for the new mother and baby. Education was included to cover basic newborn care as well as danger signs, new mom care and when to call the doctor. During this class,
®
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Nursing for Women’s Health
a certified car seat technician discusses the importance of car seat safety and schedules appointments to install the car seat for the families. The discharge class also includes important follow-up instructions for new parents for both the baby and the mother. Using hands-on demonstration, parents learned to care properly for circumcisions and umbilical cords. The parents are given information about the class starting in childbirth education classes and also the preadmit clinic. They also are receiving information on admission to the unit to encourage attendance any day until discharge.
Evaluating the Results Overall, the implementation of the process change has affected the unit and organization positively. Before the initiation of the preadmission clinic, average patient admission to initiation of oxytocin averaged 1.5 hours for our induction of labor patients. After 1 year, among patients who attended the preadmission clinic, average admission time to initiation of oxytocin has decreased to 30 minutes. This change pleased not only our patients (see Box 3 for patient comments), but also our physicians, midwives, nurses and support staff. The reduction in admission time and improvement in patient education have allowed for more time for the admission nurse to interact with the patient, outside of completing paperwork. Marie, a labor specialist on the unit, said the new process has helped tremendously with time management. “Now I don’t need to spend 1 or 2 hours completing paperwork before starting the induction,” she said. After initiation of the preadmission clinic and discharge class, patient satisfaction ratings improved for both admissions and discharge based on the Press Ganey database for specific
Volume 15
Issue 2
box 3
Comments From Patient Surveys The thing you liked best about the preadmission visit: • “It was a very sincere person-to-person level.” • “I was able to have all the paperwork done ahead of time.” • “Getting to sign all the papers beforehand, and just feeling easier about the induction.” • “All information covered before day of surgery.” • “I didn’t have to answer all the questions on day of labor.” • “The fact I didn’t have to do it all on the same day.” General comments: • “Really learned a lot, very comfortable and friendly environment.” • “Very informative with a caring atmosphere and genuine concern for the patient.”
viding individualized one-to-one teaching that is client-centered during our preadmission process has prepared the patient to have a positive labor experience (see Box 3). Providing discharge teaching in the group setting fosters relationships and improves the learning experience of the patient and family. Sheila, a mother-baby nurse on the unit, believes that the education is also more consistent, because for the majority of the time the same nurse is providing the instruction day after day. She also said, “I can do other things to prepare the couplet for discharge other than teaching and get the family discharged in a more timely manner.” The process change aligned the unit with the family-centered care approach in which it has based its model of patient care. As an ongoing process, the unit continues to find ways to improve the preadmission clinic and discharge class to support the continuing needs of our patients. NWH http://nwhTalk.awhonn.org
• “I liked coming one day early to postpone arrival time on date of surgery and ease of coming in for c-section.”
References
• “The preadmission process made it easier for me.” The thing you liked least about the preadmission visit: • “Chair wasn’t very comfortable, but other than that it was a great visit!” • “The epidural/spinal video.”
questions selected. The Press Ganey results for the specific admission questions pertaining to the Family Birth Center before change are listed along with the comparison and improvements to these questions after the process change in Box 2. An overall rating of the admission process improved from an overall mean score of 85.7 to 92.9 for the selected questions. The same process was repeated for the discharge evaluation. The specific Press Ganey questions revealed the overall discharge rating improved from 86.2 to 90 (Box 2). In addition to improvements in patient satisfaction, the change in the registration process allowed us to handle precertifications for insurance, copayments and filing of Medicaid letters in a preadmission environment. Within the first year of this change the Family Birth Center captured a total of $27,395 in copayments previously uncollected.
Conclusion
Aston, M. (2002). Learning to be a normal mother: Empowerment and pedagogy in postpartum classes. Public Health Nursing, 19(4), 284–293. Bastable, S. B. (2006). Essentials of patient education. Sudbury, MA: Jones and Bartlett. Berman, R. (2006). Perceived learning needs of minority expectant women and barriers to prenatal education. Journal of Perinatal Education, 15(2), 36–42. Birk, D. (1996). Postpartum education: Teaching priorities for the primapara. Journal of Perinatal Education, 5(2), 7–12.
Bowman, K. G. (2005). Postpartum learning needs. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(4), 438–443. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2007). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. Journal of Perinatal Education, 16(4), 9–14. Nursing Theory Workgroup. (1990). Creating our own conceptual framework: Values and beliefs about public heath nursing in the city of Toronto. Ontario, Canada: City of Toronto Health Department.
®
Reid, J. (2007). Centering Pregnancy : A model for group prenatal care. Nursing for Women’s Health, 11(4), 382–388. Todd, L. (2004). Three not so easy steps to getting families off to a good start. International Journal of Childbirth Education, 19(3), 24–27.
The implementation of the preadmission clinic and discharge class has made a positive impact on patient education. Pro-
April
May 2011
Nursing for Women’s Health
125
Tammy Smith, MSN, RNC-ob Renece Waller-Wise, MSN, CNS, CLC, LCCE, CNL
Staff of the Family Birth Center at Southeast Alabama Medical Center (SAMC) in Dothan, AL, reviewed the literature to study best practice in patient education, Centering Pregnancy and promoting family-centered care environments. As a result, we developed an obstetric preadmission and discharge clinic. The focus of the preadmission clinic and group-format discharge class bought patients into a setting where consistent education is completed in a relaxed and controlled environment. The overall experience results in positive outcomes for patients and the hospital. This is the story of how we did it.
®
About Our Facility SAMC is a 420-bed not-for-profit regional referral center serving 600,000 residents in our geographic area. The Family Birth Center at SAMC offers a state-of-the-art facility with a familycentered approach to care, where more than 1,700 newborns are born annually in 27 labor-delivery-recovery-postpartum (LDRP) rooms. The Family Birth Center includes a Special Care Nursery (Level II) and a five-bed Maternity Evaluation (triage) unit. The primary language of the patients giving birth is English, with approximately 5 percent speaking Spanish as their primary language. Most recent data show a payer mix of 39.8 percent from private insurance. Medicaid payment accounts for 57.7 percent, including payments from Florida and
• Staff at the Family Birth
Bottom Line
Center realized that their preadmission and discharge processes could be improved.
• Collaboration among a variety of departments ensured successful change.
• Streamlined processes have resulted in increased
patient and provider satisfaction and cost savings.
Georgia. One percent of payment comes from Medicare, and 1.5 percent is private pay. A review of the statistics from the childbirth education department revealed a declining trend in childbirth class attendance. Fewer patients were attending prenatal classes, averaging only 19 percent of the primapara patient population. The goal of the department was to have 50 percent of first-time mothers Tammy Smith, MSN, RNC-OB, is the director of the Women’s Center at Southeast Alabama Medical Center in Dothan, AL; Renece WallerWise, MSN, CNS, CLC, LCCE, CNL, is a licensed perinatal clinical nurse specialist at Southeast Alabama Medical Center and an adjunct faculty member at Troy University in Troy, AL. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2011.01620.x
120
© 2011, AWHONN
attend class. Sadly, we discovered that we were not unique, with only one-third of expectant parents participating in classes nationwide (Berman, 2006). Changes in hospital reimbursement from insurance companies had placed a greater emphasis on outcome measures. We identified that many of these measures could be achieved through improvements to patient education. There was greater recognition of the importance of health education and its ability to assist in the economic goal of reducing high costs in health care. We knew that there are costs associated with developing any educational program, but we believed the cost benefit occurs when patient satisfaction increases and a lifelong relationship is established. To control costs and to realize cost savings, cost benefits or cost recovery, hospitals must develop ways to deliver patient education more economically (Bastable, 2006). Thus, the staff of the Family Birth Center at SAMC began with an original plan related to the educational needs of our patients. We reviewed best practices and evidence-based literature in an attempt to draw conclusions regarding our current practice, so that changes that could be made. A summary of the literature review follows.
Reviewing the Literature As far back as 1993, the Joint Commission recognized the importance of patient education by nurses and began establishing nursing standards for patient education. Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered. Providers must also consider the literacy level, education level and language skills of every patient during the education process. Educating the patient will increase the competence and the ability for patients to manage their care independently. There are many benefits to patient education (see Box 1). When educating a pregnant woman, including her significant other and/or family can build a larger support system for her, and motivate all involved to promote learning (Bastable, 2006). One research study we reviewed presented information on a new model of prenatal care and education. This model was based on a client-centered focus and was designed to empower the pregnant woman. This approach used group discussions to augment prenatal care during the final months of pregnancy and early months of postpartum. Group sessions are conducted in a circle to promote trust and authenticity. This circle supports socialization and moves the leader into the group as a member instead of authority figure. Participants socialize and enjoy healthful snacks while learning important information about caring for themselves and their newborns. This model of care has a positive outcome on pregnancy because of the positive influences that social support systems have for the expecting mother (Reid, 2007). Nurses often have insufficient time before discharge to fully address the concerns of new mothers and the potential prob-
http://nwh.awhonn.org
Optimum patient outcomes are achieved partly through teaching programs that are client- and family-centered of women’s childbearing experience. In light of these survey results, the reality of decreased hospital stays for postpartum families means it’s increasingly important that an educational plan including nontraditional approaches be tailored to meet the specific needs of each family.
Processes Prior to Change
lems that can occur after discharge. For new parents, the postpartum period can be emotional and is often a time of stress, change and sometimes crises. There is research that attempts to determine what learning topics are the most important to mothers. Studies indicate that the most important teaching priorities for postpartum mothers are related to postpartum complications and newborn care, with feeding the baby at the top of the list (Birk, 1996; Bowman, 2005). According to Todd (2004), a needs assessment should be conducted when initiating any education of new mothers. Asking questions that can determine the most important educational needs, as well as evaluating the patient’s pain and emotional status, will help determine if learning can occur. It will also help establish a bond between the mother and the caregiver. Todd also explains that it’s important to educate members of the patient’s support system, as well. Another study we reviewed focused on the benefits of group classes during the postpartum period and discusses the importance of empowerment. The Nursing Theory Workgroup (1990) proposed broadly that empowerment should include the practice of nurses assisting clients to recognize their own strengths, make their own decisions and be independent and self-reliant (Aston, 2002). Finally, today the care of the childbearing family requires the provision of information and support within the constraints of cost containment and shortened length of stay while meeting the needs of culturally diverse families. Declercq, Sakala, Corry, and Applebaum (2007) conducted the second national survey
April
May 2011
Although the labor experience is an exciting time for families, it can be a difficult time as well. The response to pain as well as trying to care for a newborn can be overwhelming. This reaction can inhibit the ability to learn and retain information taught during the intrapartum and postpartum course. Patient satisfaction surveys at our hospital revealed a need to improve the admission, discharge and teaching methods. To identify areas in which patients perceived a need for improvement, we reviewed the Press Ganey database to look at trends in patient satisfaction ratings. Patients reported dissatisfaction with the admission process. We reviewed specific questions from the Press Ganey Survey related to the speed of admission, courtesy of person admitting, preadmission process, explanations of test and treatments and information provided to family related
box 1
Benefits of Patient Education • Increases patient satisfaction • Improves quality of life • Improves continuity of care • Decreases patient anxiety • Effectively reduces patient complications and incidence of disease • Promotes the adherence to treatment plans • Energizes and empowers patients to become actively involved in their plan of care
Nursing for Women’s Health
121
to conditions and treatments. We also reviewed Press Ganey questions related to discharge. Specifically we looked at extent they felt ready for discharge, speed of discharge, instructions for care at home and explanation concerning baby needs (see Box 2). Due to the low patient satisfaction ratings in this area, we placed a particular focus on this in our work. We began to review our processes of education from admission to discharge and discovered that there were more processes that could be included in our project. Physicians complained that there was a delay in preparing inductions and a delay in surgery start times in the morning upon the patient’s arrival. Inconsistencies were found in the patient registration process. Some patients were registered in the emergency room while others were admitted in the birthing unit. The combined admission history and physical exam, consenting process, blood work and education averaged approximately 1 hour or more to complete. This delayed the nurse’s ability to initiate the induction of labor or prepare the patient for surgery in a timely manner. This limited amount of time also burdened the nurse to complete a large amount of work in a very short time frame. Nurses who worked the night shift often had to stay past the end of their shifts to complete work due to the patient’s arrival time. The nurse was not able to complete adequate education before the start of the patient’s labor. The information was typically rushed and the patients were not given time to ask questions. The birthing unit’s employee satisfaction surveys revealed that nurses were dissatisfied due to the inability to complete
quality work in a timely manner. Many nurses experienced delays in charting due to the increased amount of tasks involved with discharging a mother-baby dyad. Much of the education that could have been initiated on admission was not started until discharge. This bottlenecking resulted in an increase in overtime hours due to the nurse staying after the shift to complete charting. The unit’s overtime percentage for salary was above the target. In light of these issues, members of the unit began to research information to find ways to improve each of these areas in addition to our education changes. The process previously in place required patients scheduled for cesarean surgical deliveries to attend a preanesthesia clinic scheduled through the surgery department. During this appointment preanesthesia nursing assessment and surgical consent forms were initiated before the admission day of surgery. Upon admission to the birthing unit, the labor nurse completed a seemingly duplicate nursing admission assessment and unitspecific consent forms, drew blood for lab work and began the initial intrapartum education.
Planning and Preparing for Change After our literature review, which took approximately 3 months to complete, we found that evidence-based practice suggested that improvements could be made to the admission process and teaching methods. A practice change was evaluated to streamline the admission process and individualize teaching methods for patients scheduled for induction of labor and for cesarean
box 2
Press Ganey™ Patient Satisfaction Scores
122
Admission
Before Implementation (Year to Date 2005)
After Implementation (1 Year Later 2006)
(mean scores)
85.7
92.9
Speed of admission Courtesy of person admitting Preadmission process Explanations happen during tests and treatment Info family re: condition/treatment
83.9 92.9 80.0
91.1 95.8 92.2
90.9 87.5
91.7 95.1
Discharge
Before Implementation
After Implementation
(mean scores)
86.2
90.0
Extent felt ready for discharge Speed of discharge Instructions care at home Explanation concerning baby care
86.2 71.4 93.7 92.1
93.7 83.2 94.6 94.6
Nursing for Women’s Health
Volume 15
Issue 2
Involvement of all departments in changing practices ensured the success of the project deliveries. Group teaching was evaluated to streamline discharge teaching for postpartum mothers and establish a comfortable supportive environment more conducive to learning. At this point, the process of establishing a preadmission clinic and discharge class for the birthing unit began. Preparation to initiate the preadmission clinic took place 6 months before the opening of the clinic, during which time meetings were held with ancillary departments to revise processes and implement the new practice change. Involvement of all departments in changing practices ensured the success of the project.
Registration One goal was to streamline the registration process; therefore, meetings were held with this department. Previously, the patient presented in one area of the hospital to be registered and was taken to another area for treatment. Many times patients were lost within the facility. Changes to the registration process included converting an existing unit secretary position to a registration representative who would register the patients directly on the unit. This person would be able to issue a preregistration number for the mother and the newborn as well as have the patient sign forms to initiate treatment for both mother and newborn during her appointment time. The implementation of the registration representative also allowed insurance information and billing to be obtained during the preadmission process. Patients requiring precertifications for insurance, copayments and filing of Medicaid letters could be handled during this process.
Laboratory Laboratory was the second department involved in the practice change. Previously, labs were drawn either in preanesthesia clinic or on admission, which slowed the process of preparing the patient for induction of labor and/or surgery. Meetings with laboratory took place to determine the feasibility of drawing and running lab samples on Friday for a scheduled surgery on Monday. These meetings included consent from all obstetricians, anesthesiologists and pathologists to complete a complete blood count as well as a Type and Screen for surgery for these patients in advance of induction or surgery date. Plans also involved establishing a mechanism for blood samples to be obtained and analyzed in this new outpatient setting. This included a mechanism for identifying the patient at the time of the preadmission appointment with an armband that would remain in place until and including hospital admis-
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sion. This process also included a protocol for patients who refused to wear an armband until admission and for those who returned for admission without the armband. Potential time savings were identified at this point with respect to how blood work was completed by the laboratory. Under the old system, all lab work was completed as a “stat” specimen on the day of admission so that results would be available before the start of the procedure. Under the new system lab work would be run as “routine” during the preadmit visit. Serendipitously, this allowed the laboratory department to focus on more critical lab draws and resulting during the high volume times of early morning.
Preanesthesia A meeting was then held with the existing preanesthesia clinic and we determined which parts of the patient record were duplicated. It was decided that all surgery paperwork normally completed at the preanesthesia clinic would be completed during the new obstetric preadmission appointment. For convenience of the patient, the obstetric preadmission clinic would now be the only appointment the patient would have to attend. Meetings were held with anesthesia personnel, social workers and case management, along with lactation services. These meetings involved a mechanism to trigger consults with these departments when patient problems were identified during the preadmission process. This would prevent late discovery of a patient’s complications. For example, identification of a patient who may not be a candidate for an epidural or may need assistance for an early detection of a breastfeeding complication might be discovered during the preadmission visit. A process was established to refer patients who warrant consults with these issues.
Other Departments Meetings were held with the printing department to develop appointment cards with instructions on appointment date and time as well as directions to the clinic. A process for scheduling of patient appointments for the clinic and utilization of the appointment card was then determined. Networking with the systems manager for the computerized labor documentation system assisted us in the process for documentation. A new screen in the documentation system was then created to use during our preadmission appointment. This screen would include the nursing assessment, lab work, consent information and all education to be taught during the
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clinic visit. The forms could be printed and placed with the mother’s and baby’s chart for the labor nurse to view on admission. On admission, the labor nurse would only need to complete the physical assessment, initiate intravenous access and initiate fetal monitoring.
Childbirth Education Conferences were then conducted with the childbirth education department to involve our educators in determining what patient education was to be completed and what teaching methods were to be used during the preadmission appointment. Ultimately, it was decided that the preadmission clinic would be staffed from the childbirth education department, and a position was created for a designated nurse. This position was created by moving a staff nurse full-time equivalent from the birthing unit to the childbirth education department. This decision was based on the best practice idea that offering consistent teaching methods would improve the overall patient experience and learning atmosphere. Once this process was established, educational meetings took place with all staff located on the unit, as well as admitting obstetrician offices, to inform and educate these groups as to the change in process for patients with scheduled procedures.
Implementing Change The first phase of this process change—the establishment of the preadmission clinic—was in place for approximately 6 months while we evaluated the flow of the process. Minor changes were made to the process, including the physical location of the clinic. This 6-month time frame also allowed the Family Birth Center staff and ancillary services to become accustomed to the new process before initiating the next phase of the change. The second phase of the process change was to implement a class setting in which the same preadmit nurse could complete appropriate postpartum and newborn care teaching before discharge. We then began working on what information should be included in the class, teaching methods used and time frame for the class to occur. A group setting with a circular seating arrangement was decided upon based on the Centering Pregnancy approach to promote a comfortable environment that fosters socialization. The class would be called “Mom and Me Tea.” Cookies and tea would be offered to promote a relaxed environment, and it was sometimes referred to by the nickname “Tea and Teach.” The class was scheduled for 10:30 a.m. each morning before the normal discharge time of families. Multiple teaching methods are used, including videos, handouts and verbal instruction. The fathers and other support persons are encouraged to attend the class to foster support for the new mom, and teach them how to care for the new mother and baby. Education was included to cover basic newborn care as well as danger signs, new mom care and when to call the doctor. During this class,
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a certified car seat technician discusses the importance of car seat safety and schedules appointments to install the car seat for the families. The discharge class also includes important follow-up instructions for new parents for both the baby and the mother. Using hands-on demonstration, parents learned to care properly for circumcisions and umbilical cords. The parents are given information about the class starting in childbirth education classes and also the preadmit clinic. They also are receiving information on admission to the unit to encourage attendance any day until discharge.
Evaluating the Results Overall, the implementation of the process change has affected the unit and organization positively. Before the initiation of the preadmission clinic, average patient admission to initiation of oxytocin averaged 1.5 hours for our induction of labor patients. After 1 year, among patients who attended the preadmission clinic, average admission time to initiation of oxytocin has decreased to 30 minutes. This change pleased not only our patients (see Box 3 for patient comments), but also our physicians, midwives, nurses and support staff. The reduction in admission time and improvement in patient education have allowed for more time for the admission nurse to interact with the patient, outside of completing paperwork. Marie, a labor specialist on the unit, said the new process has helped tremendously with time management. “Now I don’t need to spend 1 or 2 hours completing paperwork before starting the induction,” she said. After initiation of the preadmission clinic and discharge class, patient satisfaction ratings improved for both admissions and discharge based on the Press Ganey database for specific
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box 3
Comments From Patient Surveys The thing you liked best about the preadmission visit: • “It was a very sincere person-to-person level.” • “I was able to have all the paperwork done ahead of time.” • “Getting to sign all the papers beforehand, and just feeling easier about the induction.” • “All information covered before day of surgery.” • “I didn’t have to answer all the questions on day of labor.” • “The fact I didn’t have to do it all on the same day.” General comments: • “Really learned a lot, very comfortable and friendly environment.” • “Very informative with a caring atmosphere and genuine concern for the patient.”
viding individualized one-to-one teaching that is client-centered during our preadmission process has prepared the patient to have a positive labor experience (see Box 3). Providing discharge teaching in the group setting fosters relationships and improves the learning experience of the patient and family. Sheila, a mother-baby nurse on the unit, believes that the education is also more consistent, because for the majority of the time the same nurse is providing the instruction day after day. She also said, “I can do other things to prepare the couplet for discharge other than teaching and get the family discharged in a more timely manner.” The process change aligned the unit with the family-centered care approach in which it has based its model of patient care. As an ongoing process, the unit continues to find ways to improve the preadmission clinic and discharge class to support the continuing needs of our patients. NWH http://nwhTalk.awhonn.org
• “I liked coming one day early to postpone arrival time on date of surgery and ease of coming in for c-section.”
References
• “The preadmission process made it easier for me.” The thing you liked least about the preadmission visit: • “Chair wasn’t very comfortable, but other than that it was a great visit!” • “The epidural/spinal video.”
questions selected. The Press Ganey results for the specific admission questions pertaining to the Family Birth Center before change are listed along with the comparison and improvements to these questions after the process change in Box 2. An overall rating of the admission process improved from an overall mean score of 85.7 to 92.9 for the selected questions. The same process was repeated for the discharge evaluation. The specific Press Ganey questions revealed the overall discharge rating improved from 86.2 to 90 (Box 2). In addition to improvements in patient satisfaction, the change in the registration process allowed us to handle precertifications for insurance, copayments and filing of Medicaid letters in a preadmission environment. Within the first year of this change the Family Birth Center captured a total of $27,395 in copayments previously uncollected.
Conclusion
Aston, M. (2002). Learning to be a normal mother: Empowerment and pedagogy in postpartum classes. Public Health Nursing, 19(4), 284–293. Bastable, S. B. (2006). Essentials of patient education. Sudbury, MA: Jones and Bartlett. Berman, R. (2006). Perceived learning needs of minority expectant women and barriers to prenatal education. Journal of Perinatal Education, 15(2), 36–42. Birk, D. (1996). Postpartum education: Teaching priorities for the primapara. Journal of Perinatal Education, 5(2), 7–12.
Bowman, K. G. (2005). Postpartum learning needs. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(4), 438–443. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2007). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. Journal of Perinatal Education, 16(4), 9–14. Nursing Theory Workgroup. (1990). Creating our own conceptual framework: Values and beliefs about public heath nursing in the city of Toronto. Ontario, Canada: City of Toronto Health Department.
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Reid, J. (2007). Centering Pregnancy : A model for group prenatal care. Nursing for Women’s Health, 11(4), 382–388. Todd, L. (2004). Three not so easy steps to getting families off to a good start. International Journal of Childbirth Education, 19(3), 24–27.
The implementation of the preadmission clinic and discharge class has made a positive impact on patient education. Pro-
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