SAQ #21

HOW DOES THE TEAM MAKE SURE CLIENTS AND FAMILIES ARE PREPARED FOR THE END OF SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s):
11.1 The team tells clients and families what to expect during transition or end of service.11.2 The team works with other teams, services, and organizations to determine the client’s placement and develop a follow-up plan. 11.3 The team provides the client, family, or caregiver with instructions for post-procedure care and the possible consequences of failing to follow the instructions. 11.5 REQUIRED ORGANIZATIONAL PRACTICE: The team transfers information effectively among service providers at transition points.11.6 Following transition or end of service, the team contacts clients, families, or referral organizations or teams to evaluate the transition, and uses this information to improve its transition and end of service planning.
Process Currently in Place - Evidence of Current Status
• Discharge planning is started in PAC and instructions for discharge are given as accurately as possible. (Sometimes patients discharge plans change intra or post op)
• PAC initiates CCAC, SW
• During PAC appointment, pt’s post-op needs are assessed by anesthesia to ensure that the surgeon has requested the most appropriate level of care for patient post-operatively.
• Ambulatory patients are requested to have a responsible adult drive them home and stay with them for the first night post-operatively. This information is given in PAC appointment, on day of surgery, and again post-operatively. It is included in the booklet "My surgical Journey” and on the back of the Consent form there is also a signature required from the patient or SDM that they understand this information.
• SSSU patients are aware that they are to be discharged before 9am on POD #1. Information is given to them by surgeon, in PAC appointment, and again in SSSU. Discharge orders must be on the patients chart by the time patient leaves PACU.
• Written materials are given upon discharge and verbal discharge teaching is done to patient and family members
• The SSSU provides courtesy telephone call-backs to ensure that patient pain control is adequate.
-Patient Flow is working on determining Standard Length of Stay.
The new BMS will also assist in identifying possible discharges/discharge times.
Improvement Strategy / Action Plan
July 2009-Oct 2009
PAC information pamphlet and 'My Surgical Journey' booklet printed and available.
PAC pamphlet is dispersed in the Surgeon’s office to prepare patients for their PAC appt.
My Surgical Journey booklet is given to the patient at their PC appointment.
November 2009 - February 2010
Patients having a telephone appt only, or who have their PAC appointment elsewhere are mailed their booklet with instructions. Surgical care pathways to be designed for SSSU patients
March2010-onward
Ongoing project