The National Heart Centre Singapore (NHCS) manages a high volume of cardiac patients in its inpatient wards. To enhance post-discharge care, nurse clinicians conduct follow-up calls to all discharged patients, monitoring their progress and providing advice. However, Team ‘Efficiency Enhancers’ discovered that not all calls are necessary.
Comprising nurses from various wards, the team identified several inefficiencies in the post-discharge call process. Using a structured three-stage approach, they developed solutions to optimise post discharge workflows. The team pinpointed three key root causes: time-consuming nature of contacting patients and managing callbacks, the time taken to address unrelated queries, and the lack of prioritisation in post-discharge calls.
Optimising Processes: Relooking Workflows
Previously, nurse clinicians (NC) initiated follow-up calls to all discharged patients within a week. After a two-week trial and project meetings, an innovative three-pronged solution was implemented to refine and optimise the post-discharge call process.
The team developed a comprehensive post-discharge criterion based on patients’ profiles to predetermine the necessity of these calls. With a redesigned process, NCs now screen patients into three categories. The first two categories, comprising higher-risk patients, receive post-discharge calls, while the third category, consisting low-risk patients, does not.
NC Yang Yang from Ward 44, a team member, shared, “With the new work process, I can swiftly identify and prioritise discharged patients, requiring a post-discharge call within 24 hours or a week. This allows me to dedicate more attention to addressing concerns for patients who may need it more.”
The team also emphasised patient empowerment by strengthening pre-discharge education and improving access to tailored self-care resources, including educational videos and articles. This initiative empowers patients to take charge of their recovery independently.
Posters with QR codes are strategically placed in various touchpoints in wards to raise awareness.
Additionally, the team implemented QR codes containing specific ward station contact numbers for patients to seek clarification when required. Posters displaying these QR codes are placed at various touchpoints in the ward to improve accessibility and visibility. During ward orientation, staff guide patients and their caregivers on saving these contact details. This ensures patients can reach out to their respective wards for 24/7 assistance after discharge.
Project Outcomes: Providing Right Care at the Right Place at the Right Time
Since the implementation of the revamped workflow, the team found that 95% of post-discharge patients do not require follow-up calls. The streamlined process saves a total of 4,452 hours per year, equivalent to the manpower of nearly two staff!
Team leader NC Cheong Kelli from Ward 44 shared, “Streamlining the post-discharge call process has helped nurse clinicians and ward nurses work more efficiently while ensuring patients and their caregivers feel well-supported and confident in managing their recovery at home.”
Indeed, this initiative has contributed to a more seamless post-discharge experience for patients and staff, and improved patient outcomes by addressing the needs of higher-risk patients in a timelier manner. Furthermore, staff productivity has improved, allowing nurses to redirect more time to bedside care.
Patients and caregivers are encouraged to save ward contact number for quick assistance.
Moving forward, the team has proposed rolling out an e-version of the poster as an iPad screensaver in the wards. Patients in NHCS’s wards have iPads installed at their bedside, allowing them to access parts of their medical information and seek nurses’ assistance. Having the e-poster as an iPad screensaver will enhance visibility and accessibility, providing easier access to information for patients and their caregivers.
The team’s remarkable efforts earned them the Gold Award at the Team Excellence Assessment (TEA) 2024 and was also recognised as a success story of NHCS’s GROSS (Get Rid Of Silly Stuff) initiative. Congratulations to Efficiency Enhancers!
Members of Efficiency Enhancers (L-R): Zhang Juxia, Yang Yang, Wong Wei Chi Belinda, Cheong Kelli, Lee Chin Hian and Dr Fong Meng Kum.
Members of Efficiency Enhancer:
Team Facilitator:
Dr Fong Meng Kum (Deputy Director of Nursing, Nursing Administration)
Team Leader:
Cheong Kelli (Nurse Clinician, Ward 44)
Team Members:
Lee Chin Hian (Assistant Director of Nursing, Nursing Administration)
Wong Wei Chi Belinda (Senior Nurse Manager, Ward 56)
Yang Yang (Nurse Clinician, Ward 44)
Zhang Juxia (Nurse Clinician, Nursing Administration)
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Stories from the heart
