The fictional town of Springfield has fallen on tough times. There’s corruption in the government, and money is tight. Psychiatric hospitals and homeless shelters have closed, forcing mentally ill patients into the community.
Springfield General Hospital is trying to handle an increasing number of potentially dangerous patients.
Then, early one morning, a patient who was admitted for psychosis left the hospital without discharge. Even worse, staff investigated and found this wasn’t the only occurrence: more and more mentally ill patients had been leaving without discharge, posing an increasing threat to themselves and the community.
If you were in charge of a quality improvement team addressing this problem, what would you do?
Approximately 130 students, residents, and faculty tackled this question in interprofessional teams at the IHI Open School Chapter Congress Virtual Practicum. Lakshman Swamy, MD, and Chris Worsham, MD, two residents at Boston Medical Center, designed and led the special learning activity at the 27th IHI National Forum.
The aim, for all 15 teams, was to reduce departures of mentally ill patients without discharge.
First, they had to understand the problem. Teams picked from a menu of options to learn more about what was going on — Gemba walks (a term from Lean Production that means going to the front lines), emails between staff members, and promotional materials from technology companies offering quick fixes.
The teams then used driver diagrams, cause and effect diagrams, and process mapping to understand the patient’s journey from admission to departure or discharge, and where things were going wrong.
But quality improvement, the activity leaders reminded the learners, isn’t about analysis — it’s about taking action. As the teams started testing changes, one proposed more accountability and training for the “1:1 sitters,” whose job was to observe patients and alert staff if a patient seemed likely to leave. They also implemented a code system to identify security sooner — a response team that could go to the exits on the floor and watch for patients exiting. They thought technology and more staffing could really help — but realized that would be a hard sell to the hospital’s ever cost-conscious administrators.
More PDSA cycles followed, as teams redesigned the unit to have psychiatric patients grouped together — near staff and away from exits — and added an alarm to the exit. QI facilitators at each table — a mix of Open School faculty leaders, IHI staff, and IHI’s Improvement Advisor Professional Development Program graduates — showed real-time results based on each change the teams decided to test.
Jena Kitchmaster, a nursing student at Bellin College in Green Bay, Wisconsin, said the problem was true to her experience working on a medical-surgical floor.
“It hits home,” Kitchmaster said. “This was my first experience with QI, and I liked that it was a realistic problem.”
At the end of the activity, the QI facilitators determined three finalists. Three teams, including Jena’s, were selected to present to the students while Dr. Patrick Courneya, Executive Vice President & Chief Medical Officer for Kaiser Foundation Hospitals and Health Plan, listened to determine a winner.
Courneya was impressed that the finalists didn’t jump first to technology, as too often happens in health care, and that they learned from success as well as failure. He picked a winner, “Team Spider Pig,” before the full group headed to the popular Faculty-Student Reception.
“Hearing inspirational leaders is an exciting part of the Forum, but working together is what matters the most,” Swamy said. “We are the future of health care.”