redesign the system: improving med/surg efficiencies and...

Amanda Stefancyk Oberlies, Pat Rutherford and Christine White

Hospital Flow Professional Development Program

November 2, 2016 Cambridge, MA

Redesign the System:

Improving Med/Surg

Efficiencies and Patient Flow

These presenters have

nothing to disclose.

Challenges on Medical and Surgical Units

Care teams in most medical and surgical units are facing increased demand due to shorter lengths-of-stay, aging of the population, increased complexity and acuity of patients, inefficient care processes and challenges in discharging patients with the “appropriate care” in a timely fashion. Delayed transfers of patients between nursing units and lack of available beds are significant problems that increase costs and decrease quality of care and satisfaction among patients and staff. The overwhelming majority of discharges occur on medical and surgical units, and discharge delays often create bottlenecks that negatively impact patient flow throughout the hospital.

Session Objectives

Describe innovative models for multidisciplinary

collaboration and rounding on medical and

surgical units

Identify approaches for creating clear, agreed-

upon care plans for each patient -- which are a

result of active participation of patients and their

family members, hospitalists, surgeons, nursing

staff and other care team members.

Cultivating Great Teams:

What Health Care Can Learn from Google

Psychological safety: Can team members take risks by sharing ideas and suggestions without feeling insecure or embarrassed? Do team members feel supported, or do they feel as if other team members try to undermine them deliberately?

Dependability: Can each team member count on the others to perform their job tasks effectively? When team members ask one another for something to be done, will it be? Can they depend on fellow teammates when they need help?

Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?

Meaning of work: Is the team working toward a goal that is personally important for each member? Does work give team members a sense of personal and professional fulfillment?

Impact of work: Does the team fundamentally believe that the work they’re doing matters? Do they feel their work matters for a higher-order goal?

NEJM Blog Post October 19, 2016 by Jessica Wisdom & Henry Wei

Institute of Medicine report

“The current system shows too little

cooperation and teamwork. Instead, each

discipline and type of organization tends to

defend its authority at the expense of the total

system’s function.” (2003)

Relationships shape the

communication through which

coordination occurs ...

Findings

Case Managers

NursesAttending Physicians

Physical Therapists

Nursing Assistants

Social Workers Technicians

Referring Physicians

Administrators

Patient care:A coordination challenge

Patients

For better...

Shared goals

Shared knowledge

Mutual respect

Frequent

Timely

Accurate

Problem-solving

communication

… or worse

Functional goals

Specialized

knowledge

Lack of respect

Infrequent

Delayed

Inaccurate

“Finger-pointing”communication

This process is called

“Communicating and relatingfor the purpose of task integration”

Efficiency & financial outcomes

Reduced turnaround time Increased employee productivity Reduced length of hospital stay Reduced total cost of hospital care Reduced inpatient hospitalizations Reduced total costs of chronic care Increased profit growth Improved operational excellence

Identify a work process that needs better coordination – maybe “treating our patients”

Which workgroups are involved?

Draw a circle for each workgroup and lines connecting between them • WEAK RC = RED

• MODERATE RC = BLUE

• STRONG RC = GREEN

• Color of the circle says how we are doing within each workgroup, color of the line says how we are doing between the workgroups

Relational mapping

RC = Shared Goals, Shared Knowledge, Mutual Respect, Supported by Frequent, Timely, Accurate, Problem-Solving Communication

Relational mapping of current state

WEAK RC

STRONG RC

MODERATE RCWorkgroup 1

Workgroup 2

Workgroup 3Workgroup 4

Workgroup 5

14

Example

RC matrix

Admin CC PCAs Phys PA&NP RNs ResTh

Administrative Support 1.79 1.79 1.79 1.79 1.79 1.79 1.79

Care Coordination 4.43 4.86 4.29 4.52 4.71 4.67 3.86

Personal Care Assistants (PCAs) 2.62 2.40 4.02 2.29 2.29 3.50 2.40

Physicians 3.58 4.26 3.47 4.25 4.19 3.84 3.50

Physicians' Assistants and Nurse

Practitioners (PAs & NPs) 3.75 4.29 3.39 4.30 4.55 3.96 3.20

Registered Nurses 3.37 4.08 3.70 3.55 3.98 4.22 3.49

Respiratory Therapy 2.57 2.57 2.57 3.14 3.14 3.43 4.00

Ratings of

R

a

t

i

n

g

s

b

y

© 2016 Relational Coordination Analytics, Inc. All Rights Reserved

Assessing current state

• Where is relational coordination currently working well? Where does it work poorly?

• How does this impact performance?

• What are the underlying causes?

• Where are our biggest opportunities for change?

© 2015 Relational Coordination Analytics, Inc. All Rights Reserved

Reporting backAssessing current state

• Which of our current structures support relational coordination?

• Which do not?

• Where are our biggest opportunities for change?

• Consider structures that can be developed locally (huddles)

• Also consider structures that require top leadership support (shared accountability, shared rewards)

© 2015 Relational Coordination Analytics, Inc. All Rights Reserved

Three kinds of interventions

Relational interventions to build the new relational dynamics

Work process interventions to connect new relational dynamics to improvements in the work

Structural interventions to support the new relational dynamics

Stanford University Press

Multidisciplinary Rounds at MGHAmanda Stefancyk Oberlies PhD, MBA, RN, CENPChief Executive OfficerOrganization of Nurse Leaders – MA, RI, NH, CT

Strategic Objectives at MGH

To develop improvements and innovations on nursing

care units that will:

• Improve the quality and safety of patient care

• Increase patient-centeredness

• Create more effective care teams

• Improve staff satisfaction and retention

• Improve efficiency

Leadership development of frontline staff and manager

Transformational leadership

Nurse autonomy and ownership of practice

Quality measures are tracked

Health care reform

23

The TCAB Process

Frontline teams generate new ideas: not the quality department, not administration

Testing ideas and measuring outcomes: Rapid-cycle testing facilitates change: “one nurse, one patient, one shift”

Implementing and spreading successful changes

Collaborative learning

Staff

generates

idea

Small tests

of changeSpread

TCAB at MGH

Why TCAB at MGH?

– Aligns with values and mission

– Aligns with focus on innovation

– Supports evidenced based practice

– Strategically positions MGH for the future

24

A New Role in Rounds

Green books served as catalyst

Restructured rounds in a way that created a more active

role for the nurse; formalized a role for the nurse

Changing the culture – this was difficult

One year later – more positive feedback

A New Role in Rounds

Collaboration and Satisfaction About

Care Decisions (CSACD)

Q #1 Over the past month, nurses and physicians planned together to make decisions about care for patients.

Q #2 Over the past month, open communication between physicians and nurses took place as the decisions about patients were made.

Q #3 Over the past month, decision-making responsibilities for patient care were sharedbetween nurses and physicians.

Q #4 Over the past month, physicians and nurses cooperated in making decisions regarding patient care.

Q #5 Over the past month, when making patient care decisions, both nursing and medical concerns about patients’ needs were considered.

Q #6 Over the past month, decision-making for patients was coordinated between physicians and nurses.

Q #7 How much collaboration between nurses and physicians occurred in making decisions for patients over the past month?

Q #8 How satisfied were you overall with the decisions made for patients over the past month – that is the decision-making process?

C. J. Baggs 1988

Collaboration and Satisfaction About

Care Decisions (CSACD)

Pre and Post Collaboration Results

1

2

3

4

5

6

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8

Questions

Before

After

•Always

•Complete Collaboration

•Strongly Satisfied

•Never

•No Collaboration

•Strongly Dissatisfied

C. J. Baggs 1988

AJN TCAB Series (Sept 2008 - Aug 2009)

Redesign the system: A Comprehensive Approach to Caring for Hospitalized Medically Complex Patients

Christine White MD, MATAssociate Professor-Hospital MedicineCincinnati Children’s HospitalCincinnati, Ohio

James Anderson Center for Health Systems Excellence

This presenter has nothing

to disclose

November 2, 2016

Objectives

• Recognize the importance of inpatient care

coordination for hospitalized children with medical

complexity (CMC)

• Identify challenges and opportunities for the

development and implementation of inpatient CMC

services

• Identify strategies for achieving seamless

coordination across the care continuum for CMC.

• Recognize the value of integrating bedside providers

to improve the efficiency of inpatient rounds

Complex Care Patient

4 year old male with chromosomal disorder

• Severe neurologic impairment

• Hydrocephalus s/p Ventriculoperitoneal shunt

• Epilepsy (on multiple antiepileptic drugs)

• Gastrostomy tube dependent (s/p Nissen)

• Cleft lip and palate s/p repair with tracheostomy

dependence

• Chronic respiratory failure (BiPAP dependent)

• Hypothyroidism

• Spasticity

Complex Care Patient

Specialists Involved

• Complex Care Center

• Neurology

• GI

• ENT

• Pulmonary

• Physical Medicine & Rehab

• Plastic Surgery

• Endocrinology

Utilization

• 7 medical admissions in last year

• 50 inpatient days

• 5 ICU bed days

• Average of 3 consults/admit

• Average of 25 discharge medications

Definition: Children with Complex Medical Needs

• Children with complex medical needs rapidly growing population

• Group includes children with:

• A clearly identified medical specialty home

• Neurologic impairment

• Technology dependence

Definition: Children with Complex Medical Needs

Gastrostomy

tube

Tracheostomy

tube

Neurologic impairment

(ex: cerebral palsy,

brain injury)

At Risk Population

• High utilization of hospital resources

• Increasing admissions

• At risk for medication errors

• Limited longitudinal handoff between inpatient and outpatient

Challenges and Opportunities

38

Our

History/The

Problem

2011 2013

Complex patients distributed amongst all 5 HM teams

Creation of New Complex Care Team

Remainder of neurologically impaired and technology dependent patients distributed among other 4 HM teams

-Staffed by HM attendings (350 pts/year)

-Patients from CCC cohorted onto 1Hospital medicine (HM) team

-Staffed by CCC attending (105 patients/year)

-Other general HM patients also on team

Rationale for the Creation of an

Inpatient Medical Home

• Improve care coordination

• Provide more family centered care

• Improve the safety for these at risk patients

• Develop a core group of HM attendings

• Cohort patients onto one unit (if medically

safe)

Complex Care Team

• Created to provide specialized care to this unique

patient population

• All patients who are neurologically impaired or

technology dependent admitted onto 1 HM team,

including:

• Complex Care Clinic patients

• Palliative Care patients

• Transition Adult Care Patients

• Maximum 10 Patients

Multidisciplinary Rounds

Team Members

• Hospital Medicine Attending/Fellows

• Pediatric residents

• Medical students

• Advanced Practice Registered Nurses (APRNs)

• Bedside Nurses

• Pharmacist

• Dietician

• Unit Care managers

• Social Worker

• Patient’s Primary Physician/Consultant

• Chaplain resident

Care Coordination

Care Coordination Rounds

• A once/weekly meeting with unit care managers

• The team reviews each patient’s discharge goals,

outlining tasks to be completed prior to discharge

• Discharge goals are listed and updated in the electronic health

record

• A needs assessment tool serves as the framework for

the conversation

Needs Assessment Tool

• Equipment

• Home Health Care Needs

• Private Duty Nursing

• Transportation

• Medications

• Follow-up Appointments

• Social/Family Concerns

• Education Needs

Medication Reconciliation Rounds

• Medication reconciliation completed on admission,

transfer, and discharge

• The team pharmacist reviews each patient’s current

medications with the team before rounds weekly

• Medication Pathway: As patients progress toward

reaching discharge goals, the pharmacist proactively

reviews medications and mitigates anticipated barriers:

• Prior authorizations

• Need for refills

• Secondary insurance

Multidisciplinary Handoff

• On Friday afternoons, the outgoing and oncoming

attending physicians hand off patient care

• Team members from the outpatient complex care clinics

attend facilitating planning

for the hospital to home

transition

Outcomes

49

Physicians define

medical criteria in EHR on

admission

Patient meets

medically-ready criteria

Nurse places time stamp in

EHR

Goal to leave within 2 hours of

meeting all criteria

• Patient-focused around disease process improvement• Do not aim for an arbitrary time of day

Outcomes: Discharge Efficiency

Prior Work

50

Frontline Staff Engagement

Consult Timeliness

Pharmacy Process Change

How will this process apply to complex patients

with unique discharge needs?

SMART Aim

Increase the percentage of medically complex pediatric patients discharged within 2 hours* of

meeting medically ready criteria from 50% to 80% by September 1, 2014

*If criteria were met between 9:00pm – 7:00am, patients were not expected to leave until 9am

Key Drivers

Increase the percentage of

medically complex pediatric patients

discharged within 2 hours of meeting medically ready

criteria from 50% to 80% by

September 1, 2014

Anticipation of Discharge Care Needs

Staff Engagement in Discharge Preparedness

Care Coordination

Optimization of Team Structure

Discharge Goal Identification

54

Run Chart

Cohort

Patients on

Complex

Care Team

55

Run Chart

Cohort

Patients on

Complex

Care Team

Creation of

Complex Care

Admission

Order Set

56

Complex Care Order Set

© 2013 Epic Systems Corporation. Used with permission.

Group

Patients on

Complex

Care Team

Creation of

Complex

Care

Admission

Order Set

Weekly

Multidisciplinary

Care

Coordination

Rounds

Medication

Pathway

Needs

Assessment

Tool

Role

Assignments

Bi-Weekly Start Dates (Number of Patients)

Secondary Outcomes

Median LOS: 3.1 days to 2.2 days (p = .13)

Readmission rates: 31% to 22% (p = .23)

Stakeholder Feedback

P59

Family Feedback

• Very positive feedback from families:

– “I feel like things get done faster now”

– “Yellow team has been the best thing that happened to my daughter since we have been here”

– “You guys said you talked to my pediatricians in complex care clinic and the rehabilitation physicians but I didn’t believe it until I saw you in rounds together. This makes me feel great”

– “Is discharge always this easy?”

Attending /APRN Feedback

• In a focus group, attendings and APRNs felt:

• The dedicated team makes the care of complex

patients easier and more rewarding

• Structured meetings simplified and addressed the

complex needs of these high risk patients

• Communication and care coordination with the

families, outpatient primary care providers, and

subspecialists were strengths

61

Nurse Feedback

Item Strongly

disagree %

(n)

Disagree %

(n)

Undecided

% (n)

Agree

% (n)

Strongly

agree

% (n)

More resources than before

complex care team

0% (0) 0% (0) 43% (10) 48% (11) 9% (2)

More comfortable providing care

than before complex care

0% (0) 9% (2) 39% (9) 52% (12) 0% (0)

Complex care team members are

approachable and work well with

other disciplines

0% (0) 0% (0) 23% (5) 59% (13) 18% (4)

Have the appropriate amount of

staff/resources to care for complex

care patients

9% (2) 17% (4) 35% (8) 39% (9) 0% (0)

62

Resident Feedback

• Residents perceived the new team as “an efficient way to provide

care”

• “Working with the multidisciplinary team is the epitome of care

coordination.”

• “Managing complex patients with many problems as well as thinking

about all of the ancillary things they need going home is a good

exercise in the management of the overall patient, whereas in other

rotations, you are concentrated on one problem and once they are

recovered from their short term insult, go home without another

thought about their continued care after their hospital admission.”

63

Rounds Integration of

Bedside Providers: RN led

Rounds

Overall Aim

• Standardize chronic care processes and multidisciplinary

collaboration and communication

65

SMART Aim

• Increase the weekly percentage of RNs presenting

during daily pulmonary rounds in the tracheostomy unit

from 73% to 95% by July 1st, 2017

• Increase the weekly percentage of Respiratory therapists

presenting during daily pulmonary rounds in the

tracheostomy unit from 59% to 95% by July 1st, 2017

66

RN/Respiratory (RT) led rounds

RN Script 68

Tracheostomy Unit AM Rounding Sheet – Nursing

Pt Name: Date:

Significant Overnight Events/Concerns: (Desaturations, PRN medications, vent changes, storming, seizures, abnormal labs, symptoms of respiratory illness). Please include nursing recommendations if applicable.

Upcoming Tests/Procedures:

Consent Transport needed NPO Status Trach change Labs sent Pre-op Meds

Situational Awareness Specific to this Patient:

Critical Airway Subglottic Stenosis Grade___ Malacia Breath holding Seizure Rescue Storming Plan

Behavioral Plan

Other

Education Updates:

Barriers to Prevention Standards: (CABSI, CAUTI, VARI, Pressure Ulcer, Safe Care Bundle)

Medically Ready for Discharge: (Please circle one) Yes or No Needs to be completed: Barriers?:

Respiratory Therapy Script 69

Key Stakeholder Feedback

P70

% of Staff Members who Completed the Survey

Summary of change

Resources 73

• Cohen E, Kuo DZ, Agrawal R, et al. Children with

medical complexity: an emerging population for clinical

and research initiatives. Pediatrics. 2011;127(3):529-

538.

• Statile AM, Schondelmeyer AC, Thomson JE, et al.

Improving Discharge Efficiency in Medically Complex

Pediatric Patients. Pediatrics. 2016;138(2):e20153832.

Thank You to Our Team!

• Angela Statile MD, MEd

• Laura Brower MD

• Rebecca Brehob-Bucker,

RD

• Suzan DeCicca LSW

• Stacey Litman-Padnos,

LSW

• Julie Ostrye, PharmD

• Michelle Cobble, RN

• Abbie Ball, RN

• Rhonda Petsch, RN

P74

• HM attendings/fellows

• HM APRNs

• Pediatric residents and

chief residents

• Our outpatient partners

• Our unit nurses and RTs

• Dan Benscoter, MD

• Julie Clarke, RN

• Karen Tucker MSN, MBA,

RN

• Julia Edmonson

Questions or Comments?

Comparison of Quality of Communication Before and Current

I Feel Involved Comparison

Patient Status and Plan of Care Comparison

Capacity 79

80

Total Census = 2544

Total days = 365 Days %

Median Census 7.0

Days with census of 8 65 18%

Days with census of 9 44 12%

Days with census of 10 or more 39 11%

Yellow

PDSA # 1

PDSA # 2

PDSA # 3

PDSA # 4