NUR 530 Module 7 Milestone Two Example

Milestone Two: A Draft Implementation Plan for a Next-Day Discharge Huddle on 6 South

[Student Name]

Southern New Hampshire University

NUR 530: Systems Leadership and Collaborative Practice

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: A Draft Implementation Plan for a Next-Day Discharge Huddle on 6 South

The evidence appraisal, carried out with the Iowa Model (Iowa Model Collaborative, 2017), concluded that naming tomorrow's discharges at an afternoon interdisciplinary meeting was well enough supported to pilot on 6 South. In that model, a positive sufficiency decision leads to designing and piloting the practice change, and this milestone drafts the plan for that pilot. It describes the intervention role by role, lays out a twelve-week timeline, maps the timeline to a change model and lists the resources and risks. The plan asks each discipline for a small, specific change in timing rather than extra work, tests it on one hospitalist team before extending it, and uses Kotter's steps to build the urgency and coalition that earlier attempts on the unit lacked.

The Intervention

At 2:30 each weekday afternoon, the charge nurse will lead a fifteen-minute huddle at the nurses' station attended by one hospitalist from each team, the unit pharmacist and a case manager. For each patient, the group answers two questions: could this patient leave tomorrow, and if so, what is still needed? Every item gets an owner and a time. The list of expected discharges is posted on the unit board and sent to transport, environmental services and bed management by 3:30.

The huddle is modeled on the afternoon interdisciplinary rounds that an academic medical center used to identify next-day discharges, combined with a shared checklist and daily feedback on results (Wertheimer et al., 2014). It is adapted to 6 South, where hospitalists rather than resident teams provide the medical care and a single pharmacist covers the unit.

Role-by-Role Changes

Table 1 lists the new tasks for each role on the day before and the morning of an expected discharge.

Table 1

New Tasks by Role Under the Pilot

Note. Tasks apply only to patients on the forecast list.

The largest request falls on the hospitalists, whose earlier attempt to round on discharges first collapsed because it delayed care for their sickest patients. This plan asks instead for a ten-minute review of forecast patients before rounds, with orders already drafted the afternoon before, so no patient's care is postponed.

Sequencing With a Change Model

Kotter (2012) sets out eight steps for leading change. A leader first makes the need felt and gathers a guiding group with enough standing to steer it, then shapes a vision and a strategy and communicates both widely. Next come removing obstacles so others can act and securing early, visible wins, and finally building on those wins and embedding the new way of working in the unit's culture. The model suits this pilot because both earlier attempts on 6 South skipped the first two steps and went straight to asking staff to act. Each phase of the timeline in Table 2 is tied to one or more of the steps, and each test of change follows the Plan-Do-Study-Act cycle, in which a team predicts what a small change will do, tries it, compares the result with the prediction and decides what to adjust (Langley et al., 2009).

Table 2

Twelve-Week Pilot Timeline Mapped to Kotter's Steps

Note. PDSA = Plan-Do-Study-Act.

Resources

The pilot needs time more than money. The huddle takes fifteen minutes of five people's time each weekday, about six staff hours a week. The pharmacist's afternoon reconciliation shifts work already done at midday rather than adding to it, and the hospitalists' order drafting moves existing work earlier. The charge nurse will need a protected half hour each afternoon, covered by the resource nurse, at an estimated cost of three hours of nursing time a week. Other needs are a whiteboard section for the list, a shared electronic list that transport and housekeeping can see, which the informatics team has agreed to set up, and one hour of data support each week to produce the results. No new positions are requested.

Risks and Responses

Four risks are most likely. Busy clinicians may stop attending the huddle; the response is to keep it to fifteen minutes, start on time and cancel it only by the charge nurse's decision. Patients forecast for discharge may not be ready; a missed forecast is expected and simply returns the patient to the next day's list, and the forecast accuracy will be tracked. Families may be unable to come in the morning; the unit will offer a transport voucher program already run by case management for patients without a ride. Finally, early gains may fade when attention moves elsewhere, as happened with both earlier attempts, so the plan builds weekly review and an adoption decision into its final phase.

Measures

The pilot will track the measures confirmed in Project One: the monthly share of discharges leaving before noon, the share of discharges that appeared on the previous afternoon's forecast, median order-to-departure time, 30-day readmissions and day-shift overtime. A run chart of the weekly discharge-before-noon rate will be posted on the unit board so that staff can see the effect of each test of change.

Conclusion

This draft plan pilots a daily afternoon discharge huddle on 6 South, asks each role for a small change in timing and sequences the work with Kotter's steps and PDSA cycles. It needs about nine staff hours a week and no new positions. Feedback on this milestone will shape the final change proposal in Project Two, which will add the stakeholder strategy, the evaluation design and a plan for sustaining the change.

References

Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Kotter, J. P. (2012). Leading change. Harvard Business Review Press.

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154