Transforming Care Across the Hospital

The client

Part of a 12-hospital system in the Great Lakes region, this 300-bed hospital needed to overcome deep-seated barriers to care coordination.

The challenge

To ensure a sustainable future, our client realized they must focus today on creating capacity – through reducing length of stay, improving throughput, and efficiently aligning resources with the needs of patients and families.

“Physicians, nurses, case managers and social workers now come together in daily Rapid Discharge Huddles,” said Dr. Patricia Hines, Managing Director of Novia Strategies. “This collaborative communication is beneficial for patient care progression and discharge, as well as for interdepartmental relationships.”

The approach

Through the rapid-cycle design of a new care coordination model, we demonstrated that the key to success was going far beyond a departmental care management approach to an organization-wide care initiative. The result: a true interdisciplinary approach to designing the effective systems needed to support patients’ progression and transition of care.

  • Empowering social workers: Re-designing the client’s case management model resulted
    in more effective coordination of community resources for at-risk populations and consistent coverage to support patients and clinicians 7 days a week.
  • Integrating Physician Advisors: Augmenting case management with physician advisors improved communication and enabled interdisciplinary teams to develop safe and effective discharge plans.
  • Establishing rapid discharge huddles: Rolling out huddles that incorporated the collective input of interdisciplinary clinical teams meant they could address barriers to patient care progression in a more timely, cost-effective and safe manner.
  • Reducing clinical variation: Applying evidence-based practice standards led to the development of formal processes that reduced clinical variation for all patient populations.

The results


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