One in five hospital stays are complicated by a post-discharge adverse event and one in four readmissions occur within 30 days as the result of poor discharge care caused by rushed communication and poor handoffs.
In 2011, Anne Arundel Medical Center, a community hospital located in Annapolis, Md., received a grant from the Picker Institute, an independent organization dedicated to advancing the principles of patient-centered care, to improve care transitions – especially at discharge. Picker coined the term “always event” – events that should always happen when you enter the hospital – a play on the term “never event.”
Anne Arundel developed the SMART Discharge protocol to serve as a universal “always event” protocol that engages patients and families in care transitions. SMART ensures that five key areas are always covered during hospitalization and at discharge.
Developing a SMART Solution
Anne Arundel saw a need for a simple, universal and, most importantly, patient- and family-centered framework to care transitions that the entire organization could follow as patients leave the hospital. To kick off the project, the hospital formed a steering committee composed of C-level executives, physicians, nurses, technicians and four patient and family advisors.
“The four patient and family advisors are individuals that have experienced the discharge process at Anne Arundel – either themselves or with loved ones,” said SMART Project Lead Kristina Andersen, R.N. “It just doesn’t make sense to develop and execute this type of process without input from the people who are experiencing the hospital first hand. We include them in every decision.”
The committee held focus groups to identify the hospital’s strengths and missed opportunities during the discharge process. They used that information to develop the SMART Discharge protocol to ensure that five major areas – Symptoms, Medications, Appointments, Results, Talk – are always addressed during hospitalization and at discharge.
To guide communication between care staff and patients, SMART provides patients and families with a “Be Smart, Leave SMART” journal to write down notes or questions, and a whiteboard reference to the protocol in their room. “We wanted to reformat our discharge instructions in a way that was easy to remember and that includes all the information that will help patients safely care for themselves or for family members at home,” Andersen said. “SMART is a way for us to connect with patients and focus on simple steps for improvement.”
Keys to SMART Success
Anne Arundel piloted SMART on three in-patient units before spreading it to all units in June 2013. Since the project’s inception, the hospital has observed staff members focusing greater attention on discharge care and patient needs. Anne Arundel has also noted an improvement in its HCAHPS scores.
The medical center attributes the project’s initial success to the commitment and support from hospital leadership; the collaboration between all different practices, from physicians to nurses; and the patient and family advisors. “Everything must be a multidisciplinary collaboration because it affects all of us,” Anderson said. “The patient and family advisors are critical to the project because they’ve been our compass. They changed our focus and made us realize the areas we really needed to address.”
Moving Forward the SMART Way
Anne Arundel is spreading best practices learned from SMART with help from health care organizations such as the Delmarva Foundation for Medical Care (DFMC), the Quality Improvement Organization (QIO) for Maryland and Washington, D.C. The QIO invited Anne Arundel to share its story during an August 2013 webinar.
“We immediately recognized SMART as a standout project that’s improving quality and patient safety. We want to make sure that other organizations in Maryland and across the nation know about SMART,” said DFMC Project Lead Janet Jones, R.D., C.D.E. “SMART has even led to other initiatives that support quality improvement at Anne Arundel for both the patient and family.” Anne Arundel has implemented interdisciplinary rounds – geographic rounding for physicians – and IT enhancements following the launch of SMART.
Anne Arundel believes that patients and families must be part of the process team to see success in the SMART protocol. The entire organization is committed to SMART and is continuing to measure its efforts and spread best practices.