Door-to-Doc Change Readiness Tool

Tool A: Care Process Tool

Tool B: Ready to Change?

Door-to-Doc Care Process Tool

Developed by:

Mary Ellen Bucco, MBA

Twila Burdick, MBA

Chris Modena, RN, MBA/HCM

Care ProcessAFlowChart

Acceptance Goals

• With this tool, the user will be able to answer the question: “How would our current Emergency Department (ED) care process need to change to implement the Door-to-Doc (D2D) Care Process?”

• This acceptance assessment is based on two exercises: – A walkthrough of the D2D process – A flowchart comparison of current ED processes

to the D2D Care Process.

D2D in the Front of the ED The D2D Care Process reduces the time it takes for the patient to

see a physician in the ED. It changes the patient flow to eliminate waiting in the initial care process steps.

Arrive at EDwait in waiting roomTriagewait in waiting roomRegisterwait in waiting roomBack to bedwait in treatment roomSee nursewait in treatment roomSee doctor

Typical ED Process

Arrive at EDQuick Look/Quick RegistrationGo to patient care areaSee doctor and nurse

D2D ED Process

Quick Look (not triage) identifies patients as “less sick” and “sicker” and determines the D2D process in the back.

D2D in the Backfor “Less Sick” Patients

After the patient has been seen by a physician, the D2D Care Process changes the way “less sick” patients are treated.

– “Less sick” patients are treated like patients seen in a clinic • Not lying down in an ED bed unless needed• Not being undressed unless necessary• Not waiting in patient care areas• Not occupying an ED bed for tests and treatments, but

moving to other areas – When ED volume is sufficient, less sick patients are seen in a

separate intake area• Not sized like acute ED room• Not equipped like acute ED room

– Informed Discharge conducted• Not necessarily with the original caregiver

D2D in the Back for “Sicker” Patients

For “sicker” patients, the D2D Care Process is similar to current Acute ED Care Processes.

– Regularly sized and equipped ED rooms• Patient undressed• Patient in ED bed for tests and treatments and waiting for

decision-making

For “sicker” patients who are admitted, the D2D Care Process is different in capacity-constrained EDs.

– When an inpatient bed is not available, patient care is assumed by inpatient caregivers (nursing, physicians)

• May be in space within the ED or separate from the ED

Process Flow Diagram

• A flow diagram is a graphic representation of the sequence of steps in a process.[1]

– Boxes or rectangles show process steps– Diamonds show decision points– Arrows show the direction of flow– Circles with letters show connectors

• Flow diagrams of your actual process compared to the D2D process can help identify process changes that must be made.– The D2D Care Process Flow follows

Door-to-Doc Care Process[2]

Patient Arrives

1. Quick Reg (PFS Rep) and

Quick Look (RN)

2. Sicker?(ESI 1 or 2)

3. Patient escorted to

Intake Space

(RN or Tech)

4. MSE/focused assessment, Orders

& Documentation(RN and Physician)

7. Specimen Collection

5. ED Bed Required?

6. Diagnostic Testing Required?

9. Procedure/Treatment

8. Medical Imaging

13. Patient

escorted to ED Bed

14. MSE/Focused Assessment,

Orders, Specimen Collection, Procedure and Documentation

(RN, Tech, Physician)Full Registration & Co-Pay

Collection(PFS Rep)

15. Testing

16. Treatment

17.Patient meets

Results Waiting Criteria

10.Move patient

to Results Waiting Area

11.Review of Results

19.Patient to Discharge Room for Informed

Discharge

20.Patient to IP

Unit/IP Holding Unit

21.Transfer to

another facility

Patient leaves the

EDB

B

B

No

No

Yes

Yes

A

A

Yes

No

12.Medical Decision Making

18. Patient

Remains in ED Bed

No

Intake (ESI 3- 5* )

Acute (ESI 1- 2*)

“Less Sick” Patients

“Sicker” Patients

*ESI-Emergency Severity Index [3]

Your Current ED Process FlowTo be sure you know how your current ED process

operates, do a “Walk-Through”Tips for Your Walk-Through

• Start with patient entry into the ED and end with the patient leaving the ED• Include two to three people, if possible, with each viewing the process through the

eyes of a nurse and physician, patient and physician, etc. • Conduct walk-through at different times of the day, days of the week• Make a point of noting the paper trail of charts, lab reports, referrals, transfers,

medications, etc, that accompany the process steps• At different steps ask the staff to tell you about the process step

Questions to Ask• Is this a busy or slow time?• How long on average does it take to complete a process?• Is the current process working well for patients and the staff?• Is the staffing level the same 24/7?

Use this information to construct a “high-level” flow diagram of the current process

• Use ‘sticky notes” on a large surface in a group setting to identify and arrange the steps before drawing it on paper

Patient Arrival ProcessReview the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change.Start with the first steps as the patient arrives at the ED. Check the box that best describes the magnitude of the change.

Step Description Possible Changes Staff Affected BIG Change

Medium Change

Small/No Change

1a. Quick Registration -Patient Accounting system accommodation for ‘Quick Registration-Arrangements to complete registration later in care process-Patient Registration co-located with Quick Look

Patient Registration or Business Representatives

1b. Quick Look -Eliminate triage-Co-location with Quick Registration

Nursing staff, particularly Triage Staff

2. Sicker? -Adopt “quick look” methodology (such as Emergency Severity Index) for identifying sicker and less sick patients

Nursing staff, particularly Triage Staff

3. Patient Escorted to Intake Space

-Not all patients taken to an ED Bed Techs

Caring for “Less Sick” Patients

Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change.Continue with the process for “less sick” patients. Check the box that best describes the magnitude of the change.

Step Description Possible Changes Staff Affected

BIG Change

Medium Change

Small/No Change

4. MSE/focused assessment, orders and documentation

-Jointly performed medical screening, rather than nursing and physician separate-Patient focused documentation (rather than separated by provider)-Eliminates mix of sicker and less sick patients increasing the number of patients that can be seen by a physician

Physicians, Nurses, Techs

5. ED Bed Required? -Handoff by physicians of patients who are determined to be “sicker” after medical screening exam

Physicians

6. Diagnostic Tests Required? n/a n/a

7. Specimen Collected -Less sick patients move to these areas as directed on their own

Ancillary staff

8. Medical Imaging Performed -Less sick patients move to these areas as directed on their own

Ancillary staff

9. Procedure/Treatment Performed

-Less sick patients move to these areas as directed on their own

Ancillary staff

Caring for “Sicker” Patients

Step Description Possible Changes Staff Affected BIG Change

Medium Change

Small/No Change

13. Patient Escorted to ED Bed n/a n/a

14a. MSE/focused assessment, orders, specimen collection, procedure and documentation

14b. Full Registration and Co-Pay Collection

-Complete registration at bedside Patient Registration or Business Representatives

15 Testing n/a n/a

16 Treatment

17 Patient ok for results waiting? -Patients not requiring a bed moved out of acute bed to results waiting

Physicians, Nurses, Techs

18. Patient Remains in ED Bed

Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change.Continue with the process for “sicker” patients. Check the box that best describes the magnitude of the change.

Decision-Making and Leaving

Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change.Continue with the decision making process and leaving the ED. Check the box that best describes the magnitude of the change.

Step Description Possible Changes Staff Affected BIG Change

Medium Change

Small/No Change

10. Move Patient to Results Waiting Area

-Less sick patients don’t own a bed Physicians, Nurses, Techs

11. Review Test Results -May involve handoff from original caregiver Physicians, Nurses, Techs

12 Medical Decision Making

19. Patient to Discharge Room for Informed Discharge

-Utilize standardized approach for discharge and completion of registration and co-pays as needed-Separate location for discharge process-May involve handoff of care

Physicians, Nurses, Patient Registration or Business Representatives

20 Patient to IP Unit/IP Holding

-Admitted patient care assumed by inpatient care providers

Inpatient and ED nurses, physicians

21. Transfer to another facility

n/a n/a

Next Step

• Review the results of the comparison of your current process with the D2D Care Process.

• Now that you have identified the magnitude of the changes that will be required to implement D2D in your ED, the next step is to determine whether the critical success factors for acceptance of these changes are in place.

• Proceed to the next tool:Ready to Change?

B

Ready to Change?

Developed by:

Mary Ellen Bucco, MBA

Jill Howard, MS

Kathie Orlay, BS

Ready to Change?

B

Acceptance Goals

• With this tool, the user will be able to answer the question: “Do we have the critical success factors in place to begin making the changes identified in Tool A?”

• The answer is based on an appraisal of key stakeholders regarding critical change acceptance success factors. This snapshot is helpful in gauging the degree of success (or kind of weather) you will experience, as well as addressing barriers.

Care ProcessAFlowChart

Change Concepts• Building a strong team is an essential step to ensure success with

any change efforts. John P. Kotter writes about the importance of creating a “guiding coalition” which will both launch and sustain the change.[4]

• Permitting obstacles to block the “new vision” is one of the common mistakes made when introducing complex change to an organization. Hence, addressing potential challenges up front is vital to the outcome of such initiatives.

• Understanding the rationale for change and further how it will impact individuals is another area often overlooked. Helping people identify these aspects of the desired change, will aid in transitioning effectively to a new ED model which will impact your patient safety.

• William Bridges, a renowned executive consultant, remarks that “change is situational… transition is psychological.” [5] (see statement 7 on ED D2D Readiness Barometer)

Barometer Instructions• Ask members of your Emergency Department leadership and

other key stakeholders to complete the ED D2D Readiness Barometer individually.– The tool should be administered in two phases; Phase I, (statements

1-3) before a decision is made to proceed with the change and Phase II (statements 4-7) once the change process is underway.

• Compile the results, and report both individual and combined scores.

• Compare results with the ED D2D Readiness Barometer Interpretation grid.

• Conduct a discussion about:– differences of opinion– areas in which potential barriers exist– steps needed to ensure preparedness

• Determine whether to continue with the implementation of D2D tools.

• Your decision may be to stop at this point.

ED D2D Readiness BarometerPhase I

Critical Change Acceptance Success Factor True= 10 points

Not True= 0 points

1. We have senior leadership commitment to this ED D2D change initiative, including an executive sponsor and an ED physician champion.

2. ED staff members understand the need for change, e.g., they are aware of patient complaints, LWOT rate, staff retention or negative image.

3. People know the outcomes needed from this change and how these impact the overall safety of our patients.

Total

These first three statements represent “must haves” in order to gain enough momentum to initiate the change. Refer to Kotter’s book, Leading Change, and chapter entitled The Guiding Coalition.[6]

Gauge and AddressReadiness

• Study and match individual and group scores with the following Barometer.

• Reference “Planning Tips to Consider” in the following Barometer to be certain you cover areas of concern that will impact acceptance.

• Proceed according to the recommendations for the appropriate Phase.

Ready to Change?

B

Readiness Barometer: Interpretation

Phase I Score Readiness Scale Planning Tips to Consider

0-20 Stormy • Roadblocks will hinder success. • Get CEO commitment and ownership. • Engage leadership in the value of this change before beginning.• Be clear about the impact the ED Redesign will have on patient

safety, and the outcomes expected.• Address all of your leadership and executive issues before

moving through the organization with this initiative.

If your score is less than 30, create action plans with the recommendations in mind that you find in this Readiness Barometer Interpretation grid, Phase I.

Refer to Brien Palmer’s Making Change Work[7] to design methods you can use to increase leadership commitment.

ED D2D Readiness Barometer Phase II

Critical Change Acceptance Success Factor True= 5 points

Not True= 0 points

4. We have the staff, departments and resources to move forward on this initiative, e.g., a project leader, trainers and clinical staff.

5. We can measure performance, i.e., LWOTs, Door to Doc times and total visits by disposition.

6. We have researched success in action, i.e., visiting healthcare systems that have implemented this change.

7. We know exactly how to embed this change into our organization, so that we will gain acceptance from staff and support departments. We know how to help people through the transition.

Total

If your score is 20, congratulations! Proceed with your plans for change, using the Readiness Barometer Interpretation grip, Phase II. Be sure to consider additional tips on sustaining change.

Readiness Barometer: Interpretation

Phase II Score Readiness Scale Planning Tips to Consider

0-5 Rainy • Expect delays.• Expect to provide substantial support to launch the program.• Put together a timeline on which leadership places their

“fingerprints” in support of actions needed.

10-15 Cloudy • Start slowly and gain momentum. • Assess the roadblocks and identify impediments to these efforts. • Your organization requires care and nurturing, though this project

can succeed with action to remove potential barriers.• Assess the amount of change your organization can take on at

this time, and apportion it out appropriately.

20 Sunny • You are ready for this change. Conditions are favorable.• Read and apply what you learn about managing change.• Carefully construct the project plan and launch this effort. • Keep leaders involved and owning the changes. • Use the additional tools mentioned in “Organizing for Change.”

Sustaining Change

• Use information shared in the group to build a plan that will address acceptance issues as you proceed. Continue candid dialogue with those involved.

• Read William Bridge’s Managing Transitions, Making the Most of Change[5] about the psychological aspects of a change effort, to remain astute to human behaviors that can impede your progress.

• Consider how you will integrate new employees into the new ED model, to ensure understanding of the process.

• Re-administer the Readiness Barometer later in the process to see whether improvement has been made. Address areas of concern.

Next Steps

• The results of this tool are purely for you and your organization’s information.

• If you are interested in attending a training session, please feel free to complete the letter of intent form and return it to Chris Hund at chund@aha.org by 4/28/10 regardless of your results.

• Training locations will be based on area interest.

References

[1] Brassard M. The Six Sigma Memory Jogger II. Salem, NH: Goal/QPC. 2002.

[2] Burdick TL, Cochran JK, Kisiel S, Modena C. Banner Health / Arizona State University Partnership in Redesigning Emergency Department Care Delivery Focusing on Patient Safety. 19th Annual IIE Society for Health Systems Conference. 8 pages on CD-ROM. New Orleans, LA; 2007.

[3] Eitel D, Wuerz RC. The ESI Implementation Handbook. Emergency Nurses Association Ed. 1997-2003.

References continued

[4] Kotter JP. Leading Change. Harvard Business School Press. Chapter 4: Creating the Guiding Coalition. pp. 51. 1996.

[5] Bridges W. Managing Transitions: Making the Most of Change, 2nd edition. Cambridge, MA: Da Capo Press. Chapter 4: Leading People Through the Neutral Zone. pp. 54. 2003.

[6] Kotter JP, Cohen DS, The Heart of Change: Real-Life Stories of How People Change Their Organizations . Boston MA: Harvard Business School Press; Step 2: Build the Guiding Team. pp. 37. 2002.

[7] Palmer B. Making Change Work. Milwaukee, WI: Quality Press; Chapter 1: Measure Your Organization’s Readiness for Change, pp. 1. 2004.