Draft Final Report due 11/26.docx - University of Michigan



University of Michigan Health SystemVon Voigtlander Women’s HospitalImproving Obstetrics Patient DischargeFinal ReportSubmitted To:Dr. Elizabeth LangenClinical Assistant ProfessorUniversity of Michigan Health Systems Department of Obstetrics and Gynecology1500 E. Medical Center Dr.Ann Arbor, MI 48109Jackie Lapinski and Matthew ShirerLean Coaches and CoordinatorsUniversity of Michigan Health System1500 E. Medical Center Dr.Ann Arbor, MI 48109Professor Mark Van OyenAssociate ProfessorUniversity of Michigan Industrial and Operations Engineering Department1205 Beal Ave.Ann Arbor, MI 48109Submitted By:IOE 481, Team VIJoe CaprinoRobbie FultonChristine GonzalezLinnea JohnsonDate Submitted: December 10, 2013TABLE OF CONTENTS TOC \h \z \t "Style1,1,Style2,2" EXECUTIVE SUMMARY PAGEREF _Toc374297400 \h 3Background PAGEREF _Toc374297401 \h 3Methodology PAGEREF _Toc374297402 \h 3Findings PAGEREF _Toc374297403 \h 4Conclusions PAGEREF _Toc374297404 \h 5Recommendations PAGEREF _Toc374297405 \h 5INTRODUCTION PAGEREF _Toc374297406 \h 6BACKGROUND PAGEREF _Toc374297407 \h 6GOALS AND OBJECTIVES PAGEREF _Toc374297408 \h 7KEY ISSUES PAGEREF _Toc374297409 \h 8PROJECT SCOPE PAGEREF _Toc374297410 \h 8METHODS PAGEREF _Toc374297411 \h 9Literature Search PAGEREF _Toc374297412 \h 9Observation and Shadowing PAGEREF _Toc374297413 \h 9Interviews PAGEREF _Toc374297414 \h 9Surveys PAGEREF _Toc374297415 \h 9Data Research PAGEREF _Toc374297416 \h 10FINDINGS PAGEREF _Toc374297417 \h 12CONCLUSIONS PAGEREF _Toc374297418 \h 14RECOMMENDATIONS PAGEREF _Toc374297419 \h 14Visual Hospital Computer Software PAGEREF _Toc374297420 \h 14Rounding Efficiency PAGEREF _Toc374297421 \h 15Breastfeeding Education PAGEREF _Toc374297422 \h 15Expected Impact PAGEREF _Toc374297423 \h 16REFERENCES PAGEREF _Toc374297424 \h 17APPENDICES PAGEREF _Toc374297425 \h 18EXECUTIVE SUMMARYThe Von Voigtlander Women’s Hospital has very high patient demand and the Obstetrics Department has found that they are unable to meet the established target discharge times. Because of this high demand, the Clinical Assistant Professor wants to maximize the efficiency of the discharge process, which is considered to be all steps and tasks that take place between a baby being born and the mother and baby leaving the hospital. Patients and staff are not satisfied with the process in its present state and therefore, the Clinical Assistant Professor has asked IOE 481 Project Team #6 to observe the current discharge process and to collect data to develop solutions to the following goals: receive the highest satisfaction ratings from both patients and staff, and minimize the time patients spend in the discharge process.BackgroundThe Von Voigtlander Women’s Hospital birthing unit is extremely popular among expectant mothers, delivering approximately 3,800 babies per year. Although the hospital contains 48 private maternity rooms, they are frequently full. Based on 5,725 historical data points over the last 1.5 years, ranging from January 31st, 2012 – June 30th, 2013, vaginal deliveries account for 68.5% of all deliveries and Caesarean sections account for the other 29.6%. The obstetrics staff often find it difficult to discharge patients within the target times of 24 hours for a vaginal delivery and 48 hours for a Caesarean delivery. From the historical data, the average discharge time for a mother after a vaginal delivery is 33.5 hours and the average discharge time for a mother after a Caesarean delivery is 52.8 hours. Missing these targets leads to frustration for both the staff and the patients and sometimes, in extreme cases, can result in turning expectant mothers away. Achieving the target discharge times will decrease overall frustration with the current process and will provide a more satisfying experience for all parties involved. MethodologyThe team performed six types of tasks to evaluate and improve the current obstetrics discharge process at V.V. Women’s Hospital.Conducted an extensive literature searchThe team conducted a literature search to obtain background knowledge on the discharge process and learn appropriate medical terminology. The literature search also aided in selecting further methods.Observed the discharge process through shadowingShadowing helped the team gain first-hand experience on the discharge process and gave insight into possible issues involved with the process. The team performed approximately 40 hours of shadowing.Interviewed hospital staffHospital staff involved in the discharge process were identified and interviewed. These interviews were useful in that they helped identify issues that the hospital staff, who experience the discharge process daily, deemed pertinent. The team developed a process flow through the interviews. A total of 7 different departments were interviewed.Surveyed patients and care providersSurveys of both patients and providers were conducted to collect data on satisfaction and experiences with the discharge process. The surveys also captured demographics of the patient population. The demographic data was used to identify possible attributes that may correspond to a faster or slower discharge time. Five different distribution areas were chosen by the team to ensure a diverse group of demographic data was represented in the sample. The team collected 115 surveys from providers and 151 from patients.Analyzed historical dataThe team obtained historical data from the hospital data administrator, for the past 1.5 years (from January 2011 to September 2013). The team obtained descriptive statistics, and also completed a regression analysis to formulate a model that could predict discharge time based upon several input variables.FindingsFrom the observations, surveys, interviews, and historical data analysis, the team compiled the following findings. The findings are listed below based on highest significance to the conclusions and recommendations. First Time Mother EducationIt was found that first time mothers typically take longer to be discharged. First time mothers are new to the process so special attention should be given to ensure a proper understanding of caring for themselves as well as their newborn.Type of birth and parity (the number of times a female has given birth) were the 2 factors that correlated most to dischargeFirst time mothers discharges take 0.67 of an hour longer for vaginal deliveries and 2.62 hours longer for Caesarean deliveries than non-first time mothersBreastfeeding EducationBreastfeeding was identified as one of the most prominent concerns from both patient and provider perspectives.31% of patients reported that their biggest concern with going home early is uneasiness with breastfeeding10% of providers reported that breastfeeding was a top cause of delay in the discharge processCommunicationInterdepartmental communication is often lacking. Providers are often so busy that this communication does not always happen. Improving communication between departments can help the discharge process run more efficiently.ConclusionsThe patient status is not always known between departments. Obstetrics and pediatrics are usually unsure where the other is in the discharge process and if they have cleared the patient for discharge.The patient survey results show that the most common concern for mothers leaving the hospital is breast feeding. The patient survey results also show that first time mothers are the least satisfied with the discharge process and tend to struggle with the education for taking care of themselves and their newborn. The historical data analysis performed shows that first time mothers take the longest to be discharged.RecommendationsThe team recommends that the Von Voigtlander Women's Hospital implement the following to achieve the project goals of meeting the target discharge times and increasing patient and provider satisfaction:Visual HospitalVisual Hospital is a computer system that allows each step of the discharge process to be logged, shows the overall progress of discharge, and identifies issues during the process (Jackie Lapinski [3]). Nurses and doctors can view and edit a patient’s discharge progress in this system. Utilization of this system will have an extremely positive effect on communication between departments. Time will no longer be wasted trying to figure out the patients’ status from other departments. If the Visual Hospital system is not feasible to implement, a simple checklist should be placed on every patients' door to indicate the progress of their discharge.RoundingRounds should be done from lowest room number to highest to maximize efficiency and eliminate wasted time. The VVWH hospital is set up such that lower room numbers are considered labor rooms. The higher number rooms (30-50’s) are postpartum rooms and are a little smaller and do not have all the equipment needed in a labor room. Therefore, patients are moved to higher room numbers within the hospital, if possible, to make sure there are enough labor rooms available for new laboring patients. If the care provider rounds from lowest room number to highest room number, they have the best chance of not missing a patient who has been moved. This format will minimize travel time. Doctors should also pay special attention to first time mothers to ensure proper education is provided. This was recommended by experienced care provider through staff interviews.Breastfeeding EducationFrom patient surveys, 32% of mothers indicated that breastfeeding was their top concern when taking their newborn home. Therefore, having lactation consultants visit mothers in need more frequently will decrease the amount of patients with breastfeeding issues. Also, more educational support should be offered to patients via paper instructions, booklets, verbal assistance, or videos. Education should be most detailed for first-time mothers and a visual cue should be placed on the patient name tag to easily identify first-time mothers. INTRODUCTIONWhen the Von Voigtlander Women’s Hospital opened in December 2011 the customer base began to grow rapidly and has not slowed down since. Patient demand has grown so fast that the hospital staff finds it difficult to keep up. With this increase in demand, maximizing the efficiency of the discharge process has become a necessity. For the scope of this project, the discharge process is considered to be all steps and tasks that take place between the time of birth and the patient/newborn leaving the hospital. As a consequence of the high demand, doctors and other hospital staff will often expedite the discharge process to make room for new patients, leaving the current patients feeling rushed (Elizabeth Langen [1]). Other patients find their stay to be unnecessarily long. In both situations, patients and staff do not feel as if the birthing unit is providing the highest quality of care in the most efficient manner. The Clinical Assistant Professor has asked IOE 481 Project Team #6 to observe the current discharge process and to collect data to develop solutions to these two issues: meeting the highest quality standards for both patients and staff and minimizing the time patients spend in the hospital. These problems have been thoroughly analyzed, and the team will recommend changes to address the Clinical Assistant Professor’s concerns. This report will discuss the project background, goals and objectives, key issues, project scope, methods, findings, conclusions, and recommendations. BACKGROUNDThe Women’s Hospital birthing unit is extremely popular among expectant mothers, delivering approximately 3,800 babies per year2. Although the hospital contains 48 private maternity rooms, they are frequently full. Vaginal deliveries account for 68.5% of all deliveries and Caesarean sections account for the 29.6%. The team acquired these values based off of 5,725 historical data points over the last 2 years, ranging from January 31st, 2012 to June 30th, 2013. The obstetrics staff often find it difficult to discharge patients within the target times of 24 hours for a vaginal delivery and 48 hours for a Caesarean delivery. Missing these targets leads to frustration for both the staff and the patients and sometimes, in extreme cases, can result in turning expectant mothers away. Many issues are leading to longer discharge times. These problems include logistical issues such as failing to obtain a car seat, arranging for transportation home ahead of time, and/or necessary equipment not being readily available to nurses and staff during the postpartum process. Some mothers/parents do not feel comfortable or prepared to leave the hospital with a newborn due to lack of education received during their stay. Finally, waiting on specialized staff, such as lactation experts and translators, can delay the process. An understanding of the current state discharge process flow is necessary to address these problems. The initial 24 hours are filled with tests and procedures for both mother and baby. These tests are visually represented in the process flow, located in Appendix 1: Process Flow. For a vaginal delivery, the first 2 hours after delivery involve one-on-one nurse care with the mother. After that, the mother will get her vital signs checked about every 8 hours and the baby will be checked every 4 hours. The baby will receive both a hearing test and a blood test at the 24th hour of life. By this time, the mother will have registered for the birth certificate and established breast-feeding if it is the desired method. In addition to the scheduled tests and checkups that the baby and mother go through, visitors and nurses are frequently moving in and out of the room to visit and deliver food throughout the day. For males, a circumcision may also be necessary, depending on the patient’s preference. The frequent visits can put extra stress on the mother who may be woken up or disturbed while trying to rest. For a Caesarean section delivery, the process is the same except it is extended approximately 12 hours. The extended time is necessary because the catheter must be taken out and the anesthesia effects need to end in the patient. During this time, the mother will attempt to ambulate. During rounds, around 6:00 AM – 7:00 AM every day, obstetricians approve the mother for discharge. If the patient is in a questionable mental or physical state, then they are not approved and the attending physician will examine them later in the day. The pediatrician does an exam on the baby during their morning rounds between 8:00 AM – 10:00 AM. If the obstetrician had approved the mother during her exam, and the pediatrician approved the baby, then the mother and newborn can leave. The final steps are filling out the discharge paperwork, providing the mother with a list of medications and giving any last advice along with a folder that contains basic information for newborn care. Achieving the target discharge times of 24 and 48 hours will decrease overall frustration with the current process and will provide a more satisfying experience for all parties involved. In addition, it will allow the hospital to function at maximum efficiency so that the process of providing care for all patients will be optimized. GOALS AND OBJECTIVESTo improve both patient and provider satisfaction with the current discharge process at V.V. Women’s Hospital, the team performed the following tasks: Conducted a literature search to obtain background informationObserved the current discharge processConducted interviews with the hospital staffSurveyed patients and providersPerformed data analysis on past patientsWith this information, the team has developed recommendations to: Eliminate waste and delays to decrease the discharge process time to achieve set targets of approximately 24 hours for vaginal deliveries and 48 hours for Caesarean section deliveriesIncrease patient and provider overall satisfaction by maintaining the quality of the discharge processKEY ISSUESThe key issues that are driving the need for this project are meeting target discharge times and performing at a level of quality that meets highest possible standards. Target Discharge TimeMeeting the target discharge times of 24 and 48 hours will increase patient and provider satisfaction. Also, the hospital will be able to provide a higher throughput of patients. Hospital is unable to meet target discharge time for both vaginal and Caesarean deliveries. Materials (prescriptions, weight scales, biliblankets, etc.) and human resources (lactation consultants, nurses, translators, etc.) necessary for process activities are not always available at the time of need causing bottlenecks in the discharge process.Patients are unprepared logistically (car seat, ride home, etc.) and/or educationally for discharge. Quality Performance The high quality of care at Von Voigtlander Women’s Hospital cannot be compromised and must remain at a high level. Patients need to feel ready and comfortable when leaving the hospital.Patients do not always feel ready for discharge due to a lack of knowledge and emotional preparedness.Quality misses, although rare, do occur. These must be kept to a minimum if not eradicated completely.PROJECT SCOPEThe project scope included any activity involving the mother, patient, or care provider during the defined discharge process time. Again, the discharge process is defined as the time from when the mother gives birth to when the mother/newborn exit the hospital building.In ScopeThe following are included in the scope of this project.Vaginal delivery discharge process and quality of dischargeCaesarean delivery discharge process and quality of dischargeDepartment of Obstetrics patients Out of ScopeThe following are excluded from the scope of this project.Family Medicine patientsMedical complications with either mother or newbornNewborns birthed in the Intensive Care Unit (ICU)Multiple baby births: twins/triplets/quadruplets/quintuplets/etc.Births where mother is cleared for discharge but newborn is not clearedBirths where newborn is cleared for discharge but mother is not clearedMETHODSThe following are the methods used to achieve the project goals of meeting the target discharge times and increasing overall satisfaction.Literature SearchThe team conducted a literature search of professional journals and published studies relating to hospital discharge in obstetrics units. Specifically, the team reviewed research on length of stay after vaginal birth, discharge process standardization, and the association between hospital obstetrical volume and maternal postpartum complications. This research provided background information, described appropriate medical terms/context, and provided ideas for data collection techniques including observations and interviews. A copy of any of the literature search material may be obtained upon request from any group member. Observation and ShadowingBy shadowing care providers, the team observed the discharge process firsthand. The team documented how the patients are educated before being discharged and how different medical staff interacts to discharge a patient. The team identified steps that delay the current discharge process, and improvements will be suggested in the conclusions and recommendations section. During the observations, the team also documented the times that certain tasks in the discharge process took place such as when the obstetrics staff, pediatrics staff, and nurses conducted tests and gave discharge orders. The team spent approximately 40 hours observing and shadowing staff.InterviewsThe team interviewed nurses, pediatricians, midwives (Certified Nursing Midwives - CNM), obstetricians, custodial staff, interpreters/translators, and home visit nurses to gain a better understanding of the current discharge process and received insight into the main issues associated with it. Certified Nursing Midwives, custodial staff, interpreters/translators, and home visit nurses were interviewed one time each and nurses, pediatricians, and obstetricians were interviewed during observations. The team used the interviews to develop a process flow diagram of the entire discharge process.SurveysThe team has surveyed both patients and providers to collect data on satisfaction and experiences with the discharge process. The surveys also captured demographics of the patient population for the purpose of attribute analysis described later on. The team and the Clinical Assistant Professor chose 4 clinics for distribution and collection of the surveys to ensure a diverse group of representative demographic data to analyze. The 4 clinics chosen were Canton Obstetrics and Gynecology, the Von Voigtlander Women's Hospital Clinic, the Briarwood Center for Women, Children, and Young Adults, and the Plymouth, Michigan Clinic. In addition, the team also surveyed patients taking part in the Michigan Visiting Nurses program. The goal of the surveys was to obtain first-hand experiences of the patients and providers, rate those experiences based upon nominal satisfaction metrics, and obtain representative demographic information. Provider surveys were developed in Qualtrics and distributed via email to all nurses, certified nurse midwives, obstetricians, and pediatricians in the VV Women’s Hospital. To develop survey questions, the team collaborated with home visit nurses, the client (clinical assistant professor), and the team coordinators. After completion, the surveys were reviewed and approved by hospital staff. The team sent out the surveys to approximately 300 patients and 130 care providers. The patient survey and survey data can be found in Appendices 4 and 5. The team was able to gather 115 survey responses out of the 130 providers that were asked to participate. This corresponds to an 88% response rate. The provider survey and survey data can be found in Appendices 6 and 7. The team distributed 100 patient surveys to each of the four clinics in order to obtain a representative sample of the patient population. The surveys were given to patients at their six week postpartum checkup. Surveys were also given to home visit nurses to bring to patients at their checkup three days postpartum. Data ResearchData from the hospital medical records database was provided through the coordinators and the systems administrator personnel. Specifically, this data included information such as time of birth, time of discharge, type of birth, patient demographic information, and re-admittance information (if applicable) for patients from January 31st, 2012 to June 30th, 2013. The team first cleaned and compiled the data into descriptive statistics, to understand the current state of the process. Then, the team completed a stepwise linear regression, after studying each input variable, to assess the significance of a model to predict length of stay. The detailed study on each input variable can be found in Appendix 2: Discussion of Regression Model. Descriptive StatisticsThe team determined several key metrics from this data. Table 1 below outlines a few important characteristics of the historical data set. Table 1. Descriptive StatisticsItemMetricUnitAvg. Vaginal Births per Day7.49Birth/dayAvg. Discharge Time33.5HoursAvg. C-Sec Births per day2.61Birth/dayAvg. Discharge Time52.8HoursAvg. Age30.28YearsAvg. Pre-Delivery Weight, Mother152PoundsAvg. Height, Mother64.6InchIn addition, the team created the following graphical aids for the breakdown of language, birth type, and race, found in Figure 1, 2, and 3 below.Figure 1. Descriptive statistics for historical data setHospital records provided 5,275 data points from January 31st, 2012 to June 1st, 2013Figure 2. Type of Birth BreakdownHospital records provided 5,275 data points from January 31st, 2012 to June 1st, 2013Figure 3. Patient Languages Hospital records provided 5,275 data points from January 31st, 2012 to June 1st, 2013As seen in Figure 1, vaginal births accounted for 68% of total births while C-section deliveries accounted for 30%. The extra 2% includes abortions. The high majority of patients, 94%, are primarily English speakers and 69% of patients are white. The next highest race of patients is black at 14% and then Asian at 9%.Stepwise Linear Regression AnalysisAfter analyzing each input variable from the historical data set, the team decided that the following list of input variables should be put into the stepwise linear regression model:AgePre-Delivery WeightHeightGravidity (for a discussion of gravidity and parity, refer to Appendix 3)ParityEnglish vs. Non-EnglishThe team ran the regression separately for vaginal and C-section births. The R2 adjusted for vaginal births was 0.27% and for C-section births it was 1.83%. These findings do confirm the provider suspicion that the most significant variables on length of stay are Gravidity, Parity, and language of the patient (language evaluated as English vs. non-English). Therefore, the team has focused on qualitative measures to ensure that these areas do not cause excessive delays. For instance, these data show that parity is significant in the model; therefore the team recommends that the providers give more attention to the education of mothers having their first or second child.FINDINGSThe methods completed by the team that produced significant findings include analyzing the historical data, observing and shadowing care providers, and distributing and collecting patient and provider surveys.Historical Data FindingsAfter analyzing the historical data, the team determined which factors led to the longest discharge times.For vaginal births, parity and language (English vs. non-English) were the most significant factors correlated to length of stay. The stepwise linear regression analysis above proves this finding.A higher parity correlated to a shorter length of discharge. Non-English speaking patients correlated to a longer length of discharge. Discharge?Time(V)=-0.52*{Parity}-1.3*{English,?0,1}Discharge?Time(CS)=-0.60*{Parity}-1.3*{Gravida}For C-section births, Parity and Gravidity were the most significant factors correlated to length of stay.A higher Parity correlated to a shorter length of discharge.A higher Gravidity correlated to a shorter length of discharge.A complete summary of all data research, including descriptive statistics and the stepwise linear regression can be found in Appendices ii, iii, and xiv.Shadowing FindingsPatients sometimes are moved from lower numbered rooms to higher numbered rooms to reduce the room cost. Doctors are usually not notified of these room changes. Provider Survey FindingsAs seen in Appendix vii, providers are equally divided among those who are generally satisfied (48.7%) or dissatisfied (51.3%) with the discharge process. Also, the staff who have worked at the hospital the longest generally appear to feel that the process is slowest. Patient Survey FindingsAfter organizing and electronically recording 130 patient surveys, the team constructed 11 tables to portray how certain factors related to answers given by the same patient. See Appendix v for cross tabulation tables that show specific correlation values. Some key notes that were taken from these responses are bulleted below. 73% of patients are using the information folders provided at discharge; therefore, hospital staff need to make sure that these are up to date and helpfulA large majority of patients, 86%, have obtained either an undergraduate degree or higher. This means that the information provided both during labor and delivery and also in the folders provided for families to take home needs to be presented in a fashion for any level of education reached by the mother and supporting family members50% of surveyed mothers are having their first baby. These are the patients that will need extra attention, education, and assurance that they are prepared to leave the hospitalWhile the majority of patients are either White, African American or Asian, the hospital staff is prepared to handle visitors who come to the hospital speaking over 100 languages. In the case where the translators and interpreters do not speak a given patient's language, there is a phone service available for communicationCONCLUSIONSThe team found the following conclusions as a result of the project:The communication between hospital staff needs to be increased, particularly in knowing the status of the patientThere is much time spent trying to figure out what has been done and what needs to be doneWill come with better communication (and a visual aid - flow chart / visual hospital)The provider survey results indicate that 51.3% of providers are generally dissatisfied with the discharge process. This shows that the discharge process needs to be improved to increase satisfaction. The results also show that staff who are newer to the hospital think the discharge process is faster than longer tenured staff, which indicates that the process may have gotten longer over time.The patient survey results show that the most common concern for mothers leaving the hospital is breastfeeding.First time mothers struggle the most with education. The survey results show that they are least satisfied with the discharge process. Also, the data shows that first time mothers often take the longest to be discharged.Doctors often miss patients during rounds because they have been moved to another room. This causes the providers to waste time traveling to the new room and further delays the discharge. Rounding from highest to lowest room number may result in doctors missing a patient in a high numbered room and not realizing until they visit that patient’s previous room that the patient has been moved. Also, the obstetricians and pediatricians usually do not know if each other's patients have been cleared for discharge or details on the status of their discharge process.RECOMMENDATIONSThe team recommends that the Von Voigtlander women’s hospital implement the Visual Hospital computer system, improve pediatrician/obstetrician rounding techniques, and increase the education on breastfeeding. Implementing these recommendations will decrease the discharge process time and increase overall satisfaction for patients and providers. Visual Hospital Computer SoftwareVisual Hospital is a computer system that allows each step of the discharge process to be logged and shows the overall progress. It also identifies when there is a roadblock in the process or an error (Jackie Lapinski [3]). This system will allow nurses and doctors to view and edit a patient’s discharge progress. Having a visual tool to show the progress of a discharge will improve communication between providers and indicate which patients are ready to be discharged. If the Visual Hospital system is not feasible to implement, a checklist should be placed on every patient's door to indicate the progress of their discharge.Figure 4. Visual Hospital Teletracking Home PageRounding EfficiencyRounds should be done from lowest room number to highest to maximize efficiency and eliminate wasted time. If a doctor realizes a patient is no longer in their assigned room they will be able to visit the patient in their new higher number room later during rounds. Doctors should ensure that first time mothers are comfortable and have the necessary information to care for themselves and their newborn.Breastfeeding EducationFrom patient surveys, 32% of mothers indicated that breastfeeding was their top concern when taking their newborn home. Therefore, lactation consultants should visit mothers that are struggling with breastfeeding more frequently. The increased visits will help the patients and providers be more satisfied with establishing breastfeeding and will reduce the number of delays related to breastfeeding concerns. Also, more personal educational support should be offered to patients from care providers during their stay at the hospital. Additionally, care providers should put more emphasis on referencing patients to the educational booklets, such as the one provided in Appendix xiii [4], upon leaving the hospital. These actions should be emphasized more for first time mothers. From the literature research performed, it has been shown that prenatal classes where breastfeeding education is included promotes a higher success rate for mothers when attempting to nurse their babies for the first time [5] [6].Expected ImpactIf these recommendations are implemented, the expected results should enable clearer communication across all forms of care providers, shorter discharge times, and more satisfied patients and providers. The University of Michigan Health System upholds a very high standard of care, which cannot be compromised to get patients in and out of rooms faster. By utilizing the Visual Hospital Discharge module, staff will be able to understand quickly and easily what has and has not been done in the discharge process. They will also be able to see immediately when and where a hold up exists, and who to contact to resolve the problem. By focusing on first time mothers, care providers will reach those patients who need the most attention, and will need to spend less time with these patients if they were to return to UMHS. REFERENCES[1] E. Langen, private communication. September 2013.[2] K. Lowry, private communication. October 2013.[3] J. Lapinski, private communication. October 2013.[4] [5] [6] i. – Process Flow ChartAppendix ii. – Discussion of Regression ModelAppendix iii. – Gravidity and ParityAppendix iv. – Discharge Process Survey (Patient)Appendix v. – Patient Survey ResultsAppendix vi. – Provider SurveyAppendix vii. – Provider Survey ResultsAppendix viii. – Process Flow Chart (General)Appendix ix. – Process Flow Chart (Nurses)Appendix x. – Process Flow Chart (OBGYN)Appendix xi. – Process Flow Chart (Pediatrics)Appendix xii. – Provider Survey ResultsAppendix xiii. – Historical Data (Descriptive Statistics)Appendix xiv. – New Mommy News: Breastfeeding Resources from Erlanger Women’s ServicesAppendix i: Process Flow ChartAppendix ii: Discussion of Regression ModelThe team composed the stepwise linear regression for the continuous, discrete, and binary variables discussed above, separate for both birth types (Vaginal and C-Sec.). The R-Squared (adjusted) is 0.27% and 1.83% (Vaginal and C-sec., respectively). This is below the 50% threshold to conclude a significant model, therefore the team found no significant model or to predict a length of discharge. However, this does not imply that these variables have no correlation on the length of stay. Instead, the team concluded that there is other “noise” effects that are not included in these data. These noise effects could be caused by a myriad of different qualitative issues – staffing/scheduling, education of the patients, desire of the patients to leave/not leave, insurance providers, laboratory work, pharmaceutical wait times, etc. VaginalC-Sec.Alpha-to-Enter: 0.15 Alpha-to-Enter: 0.15Alpha-to-Remove: 0.15Alpha-to-Remove: 0.15Response is Length of Discharge on 5Response is Length of Discharge on 5predictors, with N = 3535predictors, with N = 1282N(cases with missing observations) N(cases with missing observations)= 337 N(all cases) = 3872= 133 N(all cases) = 1415Step 1 2 3 Step 1 2Constant 33.95 33.87 33.59Constant 53.68 54.02PARITY -0.28 -0.28 -0.52PARITY -0.89 -0.60T-Value -2.38 -2.38 -2.72T-Value -4.86 -2.27P-Value 0.017 0.017 0.006P-Value 0.000 0.023English Vs Non 1.32 1.30GRAVIDA -0.26T-Value 2.08 2.06T-Value -1.51P-Value 0.037 0.039P-Value 0.132GRAVIDA 0.23S 7.32 7.32T-Value 1.59R-Sq 1.81 1.99P-Value 0.112R-Sq(adj) 1.73 1.83Mallows Cp 4.1 3.8S 8.95 8.94 8.94R-Sq 0.16 0.28 0.35R-Sq(adj) 0.13 0.23 0.27Mallows Cp 6.8 4.5 3.9Figure ii-1. Minitab output of stepwise linear regression, Vaginal and C-Sec.The findings confirm the provider suspicion that the most significant variables on length of stay are Gravidity, Parity, and language of the patient (language evaluated as English vs. non-English). Therefore, the team focused on qualitative measures to ensure that these areas do not cause excessive delays. For instance, these data show that parity is significant in the model; therefore, the team recommends that the providers give more attention to the education of mothers having their first or second child. The team gathered patient surveys over 5 different clinics, as well provider surveys from within the VVWH. With these surveys, the team analyzed and pinpointed concerns that may be causing delays, from both the patient and provider side. Appendix iii: Gravidity and ParityFigure iii-1: Gravidity/Parity distributionGravidity is the number of times a women has been pregnant, regardless if the result was an abortion, fetal death, or live birth. Parity is defined as the number of times a women has given live birth to a baby. Therefore, Gravidity starts at the origin point because a women would not be admitted to the Obstetrics department without a reasonable assumption that she is pregnant. Appendix iv: Discharge Process Survey (Patient)Appendix v: Patient Survey ResultsAppendix vi: Provider SurveyAppendix vii: Provider Survey ResultsAppendix viii: Process Flow Chart (Nurses)Appendix ix: Process Flow Chart (OBGYN)Appendix x: Process Flow Chart (Pediatrics)Appendix xi: Provider Survey ResultsAppendix xii: Historical Data (Descriptive Statistics)left3072130Mean = 68.8 kgSt. Dev. = 17.7 kg0Mean = 68.8 kgSt. Dev. = 17.7 kg0-635Mean (Vaginal Birth) = 33.5 hrsMean (C-Section) = 52.8 hrsMean (Vaginal Birth) = 33.5 hrsMean (C-Section) = 52.8 hrsAppendix xiv: New Mommy News: Breastfeeding Resources from Erlanger Women’s Services ................
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