using quality improvement methods to achieve the triple …...using quality improvement methods to...
TRANSCRIPT
Using Quality Improvement Methods to Achieve the Triple Aim in
Behavioral Healthcare OrganizationsPresented at the 16th Annual Summer Institute - July 16, 2015 - Sedona, AZ
Margie Balfour, MD, PhDChief Clinical Officer, Crisis Response Center, Tucson, AZVP for Clinical Innovation and Quality, ConnectionsAZAssistant Professor of Psychiatry, University of Arizona
Kathleen Tanner, BA, MALean Six Sigma Black BeltQuality Manager, Crisis Response Center, Tucson, AZConnections SouthernAZ
Richard Rhoads, MDFormerly CRC Medical DirectorCurrently CMO, Cenpatico Integrated Health
What is Quality?
The Institute of Medicine’s Definition of Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
2
If 99.9% were good enough
• 2 million documents will be lost by the IRS this year.
• 190 planes would crash today.
• 22,000 checks would be deducted from the wrong bank account in the next hour.
• 1300 phone calls will be misrouted in the next minute.
3The last 0.1% matters!
How are we doing in healthcare?
• 400,000 people die from preventable medical errors each year.
• This is the third leading cause of death in the US – third only to heart disease and cancer
4
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8
A call to action
• Institute of Health Care Improvement’s Triple Aim:
1. Improving the patient experience of care (including quality and satisfaction)
2. Improving the health of populations
3. Reducing the per capita cost of health care
• Institute of Medicine’s Six Aims for Improvement:
1. Safe
2. Effective
3. Patient-centered
4. Timely
5. Efficient
6. Equitable5
How do we achieve quality?
• Quality Assurance/Quality Management
• Internal review process that audits the quality of care delivered by individuals and implements corrective action to remedy any deficiencies
• Quality Improvement/Performance Improvement
• An approach to the continuous study and improvement of the process of providing healthcare
• Focuses on organizational systemsrather than individual performance and seeks to improve quality rather than maintain compliance.
6
Lessons from Toyota: The Toyota Way
“Since Toyota’s founding we have adhered to the core principle of contributing to society through the practice of manufacturing high-quality products and services. Our business practices and activities based on this core principle created values, beliefs and business methods that over the years have become a source of competitive advantage.
These are the managerial values and business methods that are known collectively as the Toyota Way.”
Mr. Fujio Cho, President, Toyota Motor Corporation
7LEAN = Toyota’s approach to process improvement in the US
What has the Toyota Way Got to Do with Healthcare?• Healthcare, as a customer experience, is often marred by
queues and waiting. This is true both for external and internal customers.
• LEAN is focused on efficient, effective process flow that produces defect-free products that meet customer expectations at a fair price.
• LEAN accomplishes this feat by
• reducing waste (e.g. waiting)
• smoothing flow through specific techniques
• Empowering front-line staff to do whatever is necessary to eliminate defects at the source (“quality at the source”)
8
How Workers are Trained, Treated & Led is Key• Healthcare is a people-intensive business and the Toyota Way
focuses very heavily on respect, training and support for employees.
• Healthcare, although supposedly made up of “teams” who deliver care is one of the most siloed of industries. Clinical disciplines are trained differently and often not trained together.
• Healthcare organizations commonly suffer from intensely hierarchical management/leadership structures. These types of structures inhibit rather assist process improvement.
9
Key Principles of the Toyota Way
Continuous Improvement
Respect for People
Challenge
Improvement
Genchi Genbutsu
Respect
Teamwork10
Example in Action: Applying LEAN atat The Crisis Response Center• Free-standing crisis facility providing psychiatric emergency care to
adults and children in Pima County, Arizona built in August 2011 with county bond funds
• Adult services include a crisis intervention clinic (CIC), 23-hr observation unit/crisis stabilization unit (CSU), and short-term inpatient unit
• Referrals from police, outside EDs, mobile crisis, walk-ins.• 800-900 Adults and 200-300 Youth per month• Under new management (ConnectionsAZ) since April 1, 2014.
11
Critical To Quality Metrics
12
Excellence in Crisis
Services
Timely
Safe
Least Restrictive
Door to Triage, Door to Doctor
LWBS
Injuries to patients
Injuries to staff
Seclusion/Restraint
% Discharged to community
Partnership
Patient satisfaction
Door to door dwell
Effective Readmissions
Police wait time
% Time on Hospital Hold
Accessible Volume stats, # visits, etc
The Problem
Patient Experience
• Long waits for triage: inability to consistently meet target of triage within 15 minutes of arrival
• Long waits in the Adult Crisis Intervention Clinic (CIC) until decision made to discharge or admit to CSU
• Patient frustration with long waits and being asked the same questions over and over
Patient Safety
• High risk patients left unattended for long periods of time.
• Staff spread out over a large area.
• Less than ½ of walk-in clients being seen by a doctor.
• Restraints occurring in clinic environment.
• Frequent calls to Security
• Staff injuries and assaults 13
Genchi Genbutsu:We engaged the front-line staff in helping us re-design the flow with the objective of maximum safety for both staff and patients and providing quick treatment so patients wouldn’t wait excessively to see a practitioner.
14
Process Changes
• Phase I: Implemented July 1, 2014
• Achieved positive outcomes without increase in resources/staff by standardizing the process and eliminating waste
• New triage process with standardized risk screen to determine how quickly and in what location patients should be seen
• High risk and involuntary patients automatically admitted to CSU
• Low/mod risk patients wait in waiting room monitored by tech
• Space used more efficiently and staff consolidated on CSU
• Redesigned documentation to reduce redundancy
• Phase II: Implemented October 1, 2014
• Improvements to BHMP staffing model
• Included addition of a BHMP assigned specifically to triage15
Decreased CIC Length of Stay
• After the Phase I Improvements, the CIC length of stay decreased from 8 hours to 2 hours
16
Decreased CSU Length of Stay
• After the Phase II Improvements, the CSU length of stay decreased from 34 hours to less than 24 hours
17
Decreased Door to Doctor Time
18
There was a 78% decrease in the wait time to see the BHMP, from 8.3 hours to 1.8 hours.
From manual audit of a random monthly sample of 100 CSU charts. Mean time from EOC Opened to first BHMP Psych Eval, Progress Note, or Brief PN. Aug data missing, point shown above is an average of Jul and Sep.
7.68.3
1.8 1.5 1.5
0
2
4
6
8
10
Jul Aug Sep Oct Nov Dec
Ho
urs
(M
ed
ian
)
Time from Arrival to BHMP Eval
0%
20%
40%
60%
80%
100%
Jul Aug Sep Oct Nov Dec
% Hours on Hospital Hold
Decreased Time on Hospital Hold
19
Decreased time spent on hospital hold allows us to better service the needs of the community medical ERs
Decreased Staff Injuries
20
0
2
4
6
8
10
12
Base Phase I Phase II
Staff Injury for ACIC/ACSU by Phase (3 Months Each)
ACSU
ACIC
Decreased calls to security
21
Shorter wait times allowed us to decrease the need to call security for help with behavior management.
0
20
40
60
80
100
Jan-Jun Jul-Dec
Emergent Calls to Security
LEVEL 1FIRE / LIFE SAFETY PLAN
1 HOUR FIRE RATED
WALL
EXIT
LEGEND
2 HOUR FIRE RATED
WALL
SMOKE WALL
FEC
1: TYPE 1, RECESSED
2: TYPE 2, REC.
TAMPER RESISTANT
3: TYPE 3, SURFACE
MOUNTED
TYPE
1FIRE / LIFE SAFETY PLAN - LEVEL 1SCALE: 3/32" = 1'-0"
SPECIAL INSPECTION FOR FIRE PROOFING BY A QUALIFIED
SPECIAL INSPECTOR
1704.10 SPRAYED FIRE-RESISTANT MATERIALS. SPECIAL
INSPECTIONS FOR SPRAYED FIRE-RESISTANT
MATERIALS APPLIED TO STRUCTURAL ELEMENTS AND
DECKS SHALL BE IN ACCORDANCE WITH SECTIONS
1704.10.1 THROUGH 1704.10.5. SPECIAL INSPECTIONS
SHALL BE BASED ON THE FIRE-RESISTANCE DESIGN AS
DESIGNATED IN THE APPROVED CONSTRUCTION
DOCUMENTS
1704.10.1 STRUCTURAL MEMBER SURFACE CONDITIONS.
THE SURFACES SHALL BE PREPARED IN ACCORDANCE
WITH THE APPROVED FIRE-RESISTANCE DESIGN AND
THE APPROVED MANUFACTURER'S WRITTEN
INSTRUCTIONS. THE PREPARED SURFACE OF
STRUCTURAL MEMBERS TO BE SPRAYED SHALL BE
INSPECTED BEFORE THE APPLICATION OF THE
SPRAYED FIRE-RESISTANT MATERIAL.
1704.10.2 APPLICATIONS. THE SUBSTRATE SHALL HAVE
A MINIMUM AMBIENT TEMPERATURE BEFORE AND
AFTER APPLICATION AS SPECIFIED IN THE APPROVED
MANUFACTURER'S WRITTEN INSTRUCTIONS. THE AREA
FOR APPLICATION SHALL BE VENTILATED DURING AND
AFTER APPLICATION AS REQUIRED BY THE APPROVED
MANUFACTURER'S WRITTEN INSTRUCTIONS.
1704.10.3 THICKNESS. THE AVERAGE THICKNESS OF THE
SPRAYED FIRE-RESISTANT MATERIALS APPLIED TO
STRUCTURAL ELEMENTS SHALL NOT BE LESS THAN THE
THICKNESS REQUIRED BY THE APPROVED
FIRE-RESISTANT DESIGN. INDIVIDUALLY MEASURED
THICKNESS, WHICH EXCEED THE THICKNESS SPECIFIED
IN A DESIGN BY 1/4 INCH OR MORE, SHALL BE
RECORDED AS THE THICKNESS SPECIFIED IN THE
DESIGN PLUS 1/4 INCH. FOR DESIGN THICKNESS 1 INCH
OR GREATER, THE MINIMUM ALLOWABLE INDIVIDUAL
THICKNESS SHALL BE THE DESIGN THICKNESS MINUS
1/4 INCH. FOR DESIGN THICKNESS LESS THAN 1 INCH,
THE MINIMUM ALLOWABLE INDIVIDUAL THICKNESS
SHALL BE THE DESIGN THICKNESS MINUS 25 PERCENT.
THICKNESS SHALL BE DETERMINED IN ACCORDANCE
WITH ASTM E605. SAMPLES OF THE SPRAYED
FIRE-RESISTANT MATERIALS SHALL BE SELECTED IN
ACCORDANC E WITH SECTIONS 1704.10.3.1 AND
1704.10.3.2
1704.10.3.1 FLOOR, ROOF AND WALL ASSEMBLIES. THE
THICKNESS OF THE SPRAYED FIRE-RESISTANT
MATERIAL APPLIED TO FLOOR, ROOF AND WALL
ASSEMBLIES SHALL BE DETERMINED IN ACCORDANCE
WITH ASTM E605 BY TAKING THE AVERAGE OF NOT LESS
THAN FOUR MEASUREMENTS FOR EACH 1,000 SQUARE
FEET OF THE SPRAYED AREA ON EACH FLOOR OR PART
THEREOF.
1704.10.3.2 STRUCTURAL FRAMING MEMBERS. THE
THICKNESS OF THE SPRAYED FIRE-RESISTANT
MATERIAL APPLIED TO STRUCTURAL MEMBERS SHALL
BE DETERMINED IN ACCORDANCE WITH ASTM E605.
THICKNESS TESTING SHALL BE PERFORMED ON NOT
LESS THAN 25 PERCENT OF THE STRUCTURAL
MEMBERS ON EACH FLOOR.
1704.10.4 DENSITY. THE DENSITY OF THE SPRAYED
FIRE-RESISTANT MATERIAL SHALL NOT BE LESS THAN
THE DENSITY SPECIFIED IN THE APPROVED
FIRE-RESISTANT DESIGN. DENSITY OF THE SPRAYED
FIRE-RESISTANT MATERIAL SHALL BE DETERMINED IN
ACCORDANCE WITH ASTM E 605.
1704.10.5 BOND STRENGTH, THE COHESIVE/ADHESIVE
BOND STRENGTH OF THE CURED SPRAYED
FIRE-RESISTANT MATERIAL APPLIED TO STRUCTURAL
ELEMENTS SHALL NOT BE LESS THAN 150 POUNDS PER
SQUARE FOOT (PSF). THE COHESIVE/ADHESIVE BOND
STRENGTH SHALL BE DETERMINED IN ACCORDANCE
WITH THE FIELD TEST SPECIFIED IN ASTM E 736 BY
TESTING IN-PLACE SAMPLES OF THE SPRAYED
FIE-RESISTANT MATERIAL SELECTED IN ACCORDANCE
WITH SECTIONS 1704.10.5.1 AND 1704.10.5.2
1704.10.5.1 FLOOR, ROOF AND WALL ASSEMBLIES. THE
TEST SAMPLES FOR DETERMINING THE
COHESIVE/ADHESIVE BOND STRENGTH OF THE
SPRAYED FIRE-RESISTANT MATERIALS SHALL BE
SELECTED FROM EACH FLOOR, ROOF AND WALL
ASSEMBLY AT THE RATE OF NOT LESS THAN ONE
SAMPLE FOR EVERY 10,000 SQUARE FEET OR PART
THEREOF OF THE SPRAYED AREA IN EACH STORY.
1704.10.5.2 STRUCTURAL FRAMING MEMBERS. THE TEST
SAMPLES FOR DETERMINING THE COHESIVE/ADHESIVE
BOND STRENGTH OF THE SPRAYED FIRE-RESISTANT
MATERIALS SHALL BE SELECTED FROM GIRDERS,
JOISTS, TRUSSES AND COLUMNS AT THE RATE OF NOT
LESS THAN ONE SAMPLE FOR EACH TYPE OF
STRUCTURAL FRAMING MEMBER FOR EACH 10,000
SQUARE FEET OF FLOOR AREA OR PART THEREOF.
N W/D U/LHALF FLANGE
TIP THICKNESS
1-HR.W/D U/L
HALF FLANGE
TIP THICKNESS
1-HR.
W/D U/LHALF FLANGE
TIP THICKNESS
1-HR.
UNDER
DECK
MINIMUM FIRE RESISTANCE RATINGS TYPE IIA
1. EXTERIOR WALLS
A) BEARING - I HOUR RATING
B) NON-BEARING - 1 HOUR RATING WHERE THE SEPARATION IS
30 FEET OR LESS. NON-RATED IN ALL OTHER AREAS.
2. INTERIOR WALLS
A) BEARING - 1 HOUR
B) NON-BEARING - NON-RATED
3. STRUCTURAL FRAME - 1 HOUR
4. SHAFTS - 1 HOUR
5. ROOF - 1 HOUR
6. FLOOR - 1 HOUR
FIRE RESISTIVE SEPARATIONS
A) B OCCUPANCY AREAS - ALLOWED TO BE NON-RATED
B) I-3 OCCUPANCY AREAS OR CORRIDORS IN OTHER OCCUPANCY
AREAS WHICH SERVE I-3 OCCUPANTS - 1 HOUR FIRE AND
SMOKE PARTITIONS (NFPA 101)
SHEET NOTES
PIMA County Facilities Management Department
Pima County
Crisis Recovery Center
150 West Congress, 5th Floor, Tucson, Arizona 85701
T: (520) 740-3085
SEAL AND SIGNATURE ARCHITECT OF
RECORD OR ENGINEER OF RECORD
AGENCY APPROVAL
KEY PLAN
More efficient use of space
Sustaining change and moving forward…
23
"Quality is not something you install like a new carpet or a set of bookshelves," he would say. "You implant it. Quality is something you work at. It is a learning process.”
- Dr. W Edwards Deming’s obituary in the Washington Post 21 December 1993
W. Edwards Deming1900-1993
Line Leadership is Critical to achieving a “LEAN” state. LEAN organizations:
• Transfer the maximum number of tasks and responsibilities to those workers actually adding value to the product.
• Have a system for detecting defects that quickly traces every problem, once discovered to its ultimate cause.
• Have a team structure that allows for the ability to stop the work process to work on eliminating the defect once and for all and accomplishing this within the work team.
We have put a line leadership structure in place that incorporates a “Lead” for the various disciplines on all shifts: nurses, techs, crisis workers, unit coordinators. 24
Line Leaders Must be Trained in LEAN Methods• These leaders must be in a position (enough time, readily
available to staff and possessing improvement knowledge/skill) to lead their employee teams in continuous improvement.
• We have just completed the first phase of training our Line Leads in the fundamentals of LEAN while simultaneously working a project so learnings can be immediately applied.
• Nurses: medication reconciliation
• Techs: property inventories
25
LEAN concepts must be hardwired into management culture• Management is here to support the line staff and remove
barriers to getting the work done.
• Shift from asking “Why didn’t they do their job?” to “Why couldn’t they do their job?”
• In a continuous quality improvement culture, we are always examining our processes and looking for opportunities for improvement.
• Some examples:
• Daily huddles with management staff to proactively address operational concerns for the day and review incidents from the previous shift
• Tracking and trending of key process indicators and sharing with staff
26
