experience from inception to implementation - nhlc / … pdfs/june 11/metro west... · experience...

Transformational LeadershipExperience From Inception to Implementation

National Healthcare Leadership ConferenceJune 11, 2007

Dr. Keith Rose

Vice President and Chief Medical Executive

North York General Hospital

Agenda

� Anesthesia Care Teams

� Coaching Teams

� Wait Time Incremental Cases

� Innovative Delivery Models

� Cataract High Volume Centre

� Total Joint Assessment Centre

� Summary – Keys to Success

Anesthesia Care Teams (ACT)– Why?

� Health Human Resource supply issue: Anesthesiologist

shortages across Ontario and Canada

� The shortage of Anesthesiologists in the health care

system has been a contributing factor in the following

results in Ontario:

� Growing surgical wait times

� Cancelled surgeries

� Operating Room closures

Anesthesia Care Teams –

Alternate Care Providers

� Anesthesia Assistant

� Registered Nurse or Registered Respiratory Therapist can,

with additional training, expand services provided by

Anesthesiologists

� Participates in the care of stable surgical patients during

local, regional, or general anaesthesia under medical

directives and under the supervision and immediate

availability of the Anesthesiologist.

� Anesthesia Nurse Practitioner

� Nurse/RT Monitor

Anesthesia Care Team Model Example

� Use of anesthesiology teams for cataract surgeries

� One anesthesiologist covers two rooms

� Provides clinical support to Nurse/RT Monitor or Anesthesia

Assistants who establish IVs, administer sedation, and patient

monitoring

� Increase cataract surgical volumes

� Maintaining patient safety

ACT Demonstration Site Project

� In August 2006, Associate Deputy Minister Hugh MacLeod invited interested Ontario hospitals to submit an Expression of Interest to develop an Anesthesia Care Team Demonstration Site

� The ministry was interested in evaluating different models of anesthesia care in pre-operative, intra-operative and post-operative settings. The government also wanted to assess the effectiveness of the ACT in Community and Academic hospitals

ACT Demonstration Site Project cont’d

� Demonstration sites are expected to run for 2 years

and will roll out in 2 to 3 phases depending on the

level of interest and availability of trained personnel:

� Phase I launched in 2006

� Phase II starting in late 2007

Expressions of Interest

� 42 Ontario hospitals submitted Expressions of

Interest to develop an ACT Demonstration Site.

These submissions covered pre-operative, intra-

operative and post-operative settings:� 31 pre-operative proposals

� 42 intra-operative proposals

� 29 post-operative proposals

� Proposals came from Community Hospitals and

AHSCs across Ontario. Hospitals in all 14 LHINs

submitted Expressions of Interest.

ACT Proposal Review Process

� Detailed criteria were used to review the proposals (in order of importance):� Merits of Proposal

� Anesthesia Shortfall

� Readiness to Proceed

� Wait List Cases

� Budget

Funded Demonstration Sites� 16 Projects

� 2 pre-operative

� 10 intra-operative

� 1 post-operative

� 3 other

� 10 Hospitals � 4 community hospitals

� 6 teaching hospitals

� 7 LHINs

� 44 Staff� 38 anesthesia assistants

� 6 registered nurses

Evaluating Demonstration Sites

� Objective:� Identify safety and efficiency of ACT model for pre-operative

assessment, intra-operative care and acute pain services

� Indicators:� Patient safety

� Clinical efficiencies

� Patient & staff satisfactions

� Methodology:� Compare prospective & retrospective data from Demonstration sites

� Compare patients treated by ACTs to patient treated without an ACT

� Data collection� Web-based database registry

Anesthesia Care Teams

Challenges

� Change management process

� New roles and relationships

� Training program

� RT/RN choice

� Funding for physicians

� Time and effort for implementation was

underestimated

Coaching Teams – Operating Rooms

What are coaching teams?

� Coaching teams are peers with experience in effective management of peri-operative resources, trained as coaches

� They assist hospitals assess their peri-operative

processes

� Based on expert panel recommendations

� First visits began in January 2006

� First return visits began in November 2006

Coaching Teams

Team Composition

� Team composition depends on the issues identified by the hospital through their Expression of Interest. Teams generally include four members from the following areas:

� One Physician

� One or two Senior Administrators

� One or two OR Leaders

Out of the 32 coaches;

� 8 are Physicians, 13 are Administrators and 11 are OR Leaders

� Affiliation ranges from teaching hospitals, community hospitals and small/rural hospitals.

Coaching Teams - Themes

� Leadership and Accountability

� Allocation of OR Resources

� Flow and Space Issues

� Data Collection

� Human Resource Issues

� Equipment and Supplies

Coaching Teams – Follow-up

Coaching follow up visit

� Occurs between 6 and 9 months

� 2-3 hour on site visit

� Senior management representation

� Perioperative team members

� Coaching team members (physician and administrative lead)

� Follow up with the team to evaluate successes/challenges

� Review and assessment of progress with action plan

� More advisory in nature

Coaching Teams – Early Observations

� Broad engagement of perioperative team and senior management

� Consensus of issues

� Readiness for change

� Coaching process has assisted with team development

� Helps provide direction for the team

� Improved access to expertise

Coaching Teams –Early Observations

� Coaching for action/trusted advisor was the right model

� Coached organizations are leveraging the model internally

� Using the coaching process for other departments

� Organizations are finding capacity, savings and improving quality

� Coaching teams have identified system problems which are being addressed

� Process mapping workshops being developed for hospitals

Coaching Teams - Challenges

� Some organizations see coaching teams as an

evaluation rather than an opportunity for learning

and growth

� Some organizations have been slow to adopt

� Implementation of recommendations

Coaching Teams – Future Steps

� Evaluation of the coaching process by University of Toronto researchers; initial work started in January 2007

� Development of follow-up visit assessment tools, development of data trend analysis and tools that measure change and improvement

� Updated website – materials for coaches and hospitals

� Toolkit of useful tools and templates created and accessible to all hospitals

Wait Time Incremental Cases

� Additional funding has been provided to perform incremental volumes in the following areas:

� MRI

� Cardiac

� Cancer surgeries

� Joints (Hips and Knees)

� Cataract surgeries

� Paediatric surgeries

� Endoscopy

� Chemotherapy visits


Accomplishments

� Decrease in wait times

� Increased efficiency

� Surgical Efficiency Target (SET)

� Process Mapping

� Standardization

� Focus on Quality


Accomplishments continued

� New IT Infrastructure

� Wait time management

� Scheduling process

� Acquisition of new equipment

� Innovative delivery models

� New surgical and anesthetic techniques

� Improved Discharge Planning


Challenges� Fixed funding (no COLA), one year only

� Short notice period

� Cannibalization� Need to focus on other system priorities

� Clawbacks for unmet targets

� Requirement for additional IT infrastructure and data collection

Innovative Delivery Models

� High Volume Cataract Centre

� Total Joint Assessment Centre

Cataract High Volume Centre

� Partnership between North York General Hospital,

Markham Stouffville Hospital, Humber River

Regional Hospital

� Dedicated ophthalmology operating room suite

� Goal: work in partnership to improve access, and

reduce wait time


� Objectives:

� Reduce the wait time for patients from to the time of

decision to treat by an ophthalmologist to time of surgery

� Improve access - increase the number of surgical cases

performed

� Improve operative efficiencies (standardization)

� Improve patient outcomes


Accomplishments:

� Cross-credentialing

� Standardized work processes (operative packs, instruments, supplies, forms)

� Process re-design

� Implementation of alternative care providers

� Effective buy-in

� No threat to referral patterns

� No threat to number of cases (financial impact)

� Significant reduction in wait time for cataract surgery


Next Steps

� Comprehensive eye care plan for the Central LHIN

� Base volume cataract surgery consolidation

� Scheduled non-cataract surgery

� Urgent non-cataract surgery


Challenges

� Change management

� New environment

� New Team

� Fee schedule – premium lenses

Total Joint Assessment Centre

� Partnership between North York General Hospital,

Markham Stouffville Hospital, York Central Hospital

� Goal: work in partnership to improve access, and

reduce wait time


� Objectives:

� Reduce wait time for patients from the point of referral

from their primary care physician to surgical assessment

and surgery

� Increase the number of surgical cases performed

� Maximize orthopedic surgical time

� Improve patient and family involvement in their plan of

care

� Improve patient outcomes


Accomplishments

� Innovative delivery model

� Inter-professional team conducts a comprehensive assessment and

develops a plan of care through to the recovery stage of the joint

replacement surgery

� Learning and Development

� Surgeons worked with clinicians to teach and monitor assessment skills

� Standardization of processes and assessment forms

� Significant reduction in wait time for hip and knee replacement

surgeries


Challenges

� Staff and physician engagement

� Fear of loss of referral patterns

� Communication with orthopedic surgeons, general

practitioners, public

Summary

Transformational Leadership – Keys to Success

� Strong Leadership

� Change management

� Systems thinking

� Innovation

� Appetite for risk

� Consistent and determined leadership

� Stakeholder engagement

� Patient focused

� Physician champions

� Understanding scope of influence and scope of control

Questions?

experience from inception to implementation - nhlc / … pdfs/june 11/metro west... · experience...

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