4/12/2016. High Reliability and Microsystem Stress. We have no financial, professional or personal conflict of interest to disclose.

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1 High Reliability and Microsystem Stress Helping leaders identify and mitigate unit level stress: Next steps towards the journey of high reliability Whittney Brady RN, DNP Jackie Hausfeld, RN, MSN, NEA-BC Objectives Quantitative metrics and qualitative measures indicative of microsystem stress Mitigate Describe mitigation and escalation strategies at the unit, microsystem and organizational levels to prevent serious harm and other types of poor outcomes in stressed systems. Discuss a systematic approach to predict stressed microsystems. We have no financial, professional or personal conflict of interest to disclose 1

2 Global Aim Develop a system to identify, mitigate and predict microsystem stress in order to prevent serious harm and other undesirable outcomes. Mitigate KEY Gray box = completed intervention Green box = what we re working on right now White box = future work Definitions Unit Level = Microsystem Inpatient System Level = Mesosystem Organizational Level = Macrosystem The First Stressed Microsystem CANCER & BLOOD DISEASES INSTITUTE (CBDI) 2

3 CBDI: Quantitative Measures Volume 56 beds in CBDI 6/13 68 beds in CBDI 2/14 80 beds in CBDI 4/ new oncology patients per year bone marrow transplants per year CBDI: Quantitative Measures Volume CBDI: Quantitative Measures Staffing 3

4 CBDI: Quantitative Measures Staffing Less Experienced Nurses CBDI: Quantitative Measures Acuity 4.0 Primary BSI Rate in CCHMC CBDI (July 2011-May 2014) 3.5 Primary BSI Rate per 1000 line days July_11 (n=1247) Aug_11 (n=1094) Sept_11 (n=1122) Oct_11 (n=1238) Nov_11 (n=1295) Dec_11 (n=1380) Jan_12 (n=1526) Feb_12 (n=1362) Mar_12 (n=1434) Apr_12 (n=1550) May_12 (n=1352) Jun_12 (n=1410) Jul_12 (n=1501) Aug_12 (n=1415) Sep_12 (n=1240) Oct_12 (n=1280) Nov_12 (n=1058) Dec_12 (n=1136) Jan_13 (n=1228) Feb_13 (n=1081) Mar_13 (n=1234) Apr_13 (n=1314) May_13 (n=1368) June_13 (n=1246) Jul_13 (n=1695) Aug_13 (n=1652) Sep_13 (n=1456) Oct_13 (n=1606) Nov_13 (n=1473) Dec_13 (n=1414) Jan_14 (n=1553) Feb_14 (n=1426) Mar_14 (n=1774) Apr_14 (n=2157) May_14 (n=2222) Month Monthly Primary BSI Rate Median BSI rate Control Limits Stressed Microsystem: CBDI Mitigate Interventions Unit Serious Harm: BSI Stabilization of current processes 2 person dressing changes Daily prevention standard rounding with real time feedback Inpatient System Increased education to float staff and review of CVC care by all staff Physician engagement in BSI prevention work Pre assignment of float staff Organization Implementation of a system to improve allocation of resources and support to deescalate system stress Implementation of a experienced based knowledge bonus 4

5 Stressed Microsystem: CBDI Outcome Blood Stream Infections per 1000 Line Days Primary Blood Stream Infection Rate in the Cancer and Blood Disease Institute (Infections / 1000 line days) Acute increase in census, phase 1 patients, relapsed refractory patients, national and Jul-11 (n=1247) Aug-11 (n=1094) Sep-11 (n=1122) Oct-11 (n=1238) Nov-11 (n=1295) Dec-11 (n=1380) Jan-12 (n=1526) Feb-12 (n=1362) Mar-12 (n=1434) Apr-12 (n=1550) May-12 (n=1352) Jun-12 (n=1410) Jul-12 (n=1501) Aug-12 (n=1415) Sep-12 (n=1240) Oct-12 (n=1280) Nov-12 (n=1058) Dec-12 (n=1136) Jan-13 (n=1228) Feb-13 (n=1081) Mar-13 (n=1234) Apr-13 (n=1314) May-13 (n=1368) Jun-13 (n=1246) Jul-13 (n=1695) Aug-13 (n=1652) Sep-13 (n=1456) Oct-13 (n=1606) Nov-13 (n=1473) Dec-13 (n=1414) Jan-14 (n=1553) Feb-14 (n=1426) Mar-14 (n=1774) Apr-14 (n=2157) May-14 (n=2222) Jun-14 (n=2143) Jul-14 (n=1437) Aug-14 (n=1680) Sep-14 (n=1560) Oct-14 (n=1678) Nov-14 (n=0800) Month (number of line days) Increased percentage of floating and inexperienced nursing Implementation of: Identification of high risk patients Improved daily CHG bathing/oral care compliance Increased awareness of high BSI-risk patients Assistance for nurses performing high BSIrisk procedures System to improve allocation of resources Monthly Blood Stream Infection Rate Average Rate of Blood Stream Infections Control Limits Stressed Microsystem: CBDI Key Findings Decrease in primary BSI rate from 1.8 primary BSIs per 1000 line days to 0.21 BSIs per 1000 line days. Prolonged stress in complex systems with high-risk patients can contribute to increased BSI rates. ing key processes and executing mitigation strategies at the unit, microsystem and organizational levels can stabilize outcomes when under stress. Building on continued learnings from CBDI helped to identify the next stressed microsystem: NICU. The Second Stressed Microsystem NEWBORN INTENSIVE CARE UNIT (NICU) CY2014 5

6 Record High Census High Acuity Major Construction New Staff NICU NICU: Record High Census 60 Volume NICU Daily Census CY 2014 Licensed Bed #59 55 Daily Census Adjusted ADC NICU ADC /01/14 01/06/14 01/11/14 01/16/14 01/21/14 01/26/14 01/31/14 02/05/14 02/10/14 02/15/14 02/20/14 02/25/14 03/02/14 03/07/14 03/12/14 03/17/14 03/22/14 03/27/14 04/01/14 04/06/14 04/11/14 04/16/14 04/21/14 04/26/14 05/01/14 05/06/14 05/11/14 05/16/14 05/21/14 05/26/14 05/31/14 06/05/14 06/10/14 06/15/14 06/20/14 06/25/14 06/30/14 07/05/14 07/10/14 07/15/14 07/20/14 07/25/14 07/30/14 08/04/14 08/09/14 08/14/14 08/19/14 08/24/14 08/29/14 09/03/14 09/08/14 09/13/14 09/18/14 09/23/14 09/28/14 10/03/14 10/08/14 10/13/14 10/18/14 Date Average Daily Census Goals Linear (Average Daily Census) NICU: High Acuity Acuity Fetal Care Patients Record number of CDH Patients with ALOS of 72 days Managing census utilizing level II and III NICUs in our region Landscape of the NICU has changed: Cincinnati Fetal Care Center 6

7 NICU: Major Construction NICU patients located on 5 different units. NICU: New Staff October, 2014 We had just over 200 RN s 94 had been hired since 1/1/2013 NICU: Quantitative Measures Volume NICU ADC by Fiscal Year FY 13: ADC 45 FY 16: ADC ADC FY12 FY13 FY14 FY15 FY16 7

8 NICU: Quantitative Measures Staffing NICU FTE s by Fiscal Year Increase in over 48 FTE s FTE's FY12 FY13 FY14 FY15 FY16 Snap Shot: Quantitative Metrics 10/19/14 10/25/14 108% occupancy to budgeted ADC (4.31) variance to budgeted HPPD 13% operational vacancy (before we added more FTEs) 1185 hours of float staff Stressed Microsystem: NICU Mitigate Interventions Unit Inpatient System PICC Team Targeted rounding ion (Watchers) Multi disciplinary Huddles 4 times per day Leadership Prevention Standard Rounds: all patients on all units. Weekly report out on all serious harm in leadership meeting. Pre-assignment of float staff. Organization Implementation of a system to improve allocation of resources Organizational support to deescalate system stress Implementation of a experienced based knowledge bonus Added FTE s 8

9 Stressed Microsystem: NICU Outcome Stressed Microsystem: NICU B4 NICU Nosocomial Infection Data 20.0 Infection per 1000 patient days Mean = 3.32/1000 pt /01/09 (n=1485) 03/01/09 (n=1326) 05/01/09 (n=1466) 07/01/09 (n=1270) 09/01/09 (n=1390) 11/01/09 (n=1390) 01/01/10 (n=1280) 03/01/10 (n=1393) 05/01/10 (n=1560) 07/01/10 (n=1261) 09/01/10 (n=1270) 11/01/10 (n=1297) 01/01/11 (n=1261) 03/01/11 (n=1459) 05/01/11 (n=1355) 07/01/11 (n=1483) 09/01/11 (n=1410) 11/01/11 (n=1429) 01/01/12 (n=1448) 03/01/12 (n=1280) 05/01/12 (n=1404) 07/01/12 (n=1423) 09/01/12 (n=1474) 11/01/12 (n=1356) 01/01/13 (n=1395) 03/01/13 (n=1463) 05/01/13 (n=1240) 07/01/13 (n=1450) 09/01/13 (n=1357) 11/01/13 (n=1594) 01/01/14 (n=1329) 03/01/14 (n=1641) 05/01/14 (n=1644) 07/01/14 (n=1657) 09/01/14 (n=1606) 11/01/14 (n=1566) 01/01/15 (n=1317) 03/01/15 (n=1289) 05/01/15 (n=1620) 07/01/15 (n=1476) 09/01/15 (n=1476) 11/01/15 (n=1560) Infection rate Average infection rate Control Limits Listening to families and staff QUALITATIVE FACTORS 9

10 NICU: Qualitative Measures Family Stress NICU Notes Issue 143 Aug 22 Aug 28 Parents Feedback Week 2 Results 4 th Floor Very Supported 50 Somewhat Supported 0 Minimally Supported - 0 Week 1 Results 6 th Floor Very Supported 12 Somewhat Supported 0 Minimally Supported 0 (this one started 8/21) 10

11 NICU: Qualitative Measures Staff Stress NICU Notes Issue 143 Aug 22 Aug 28 Staff Qualitative Stress Measure Busy night could have used more MTs Move to A Pod Yellow Move to B Pod Move to 500 Pod Orange Red

12 NICU: Staff Definitions Yellow Good day, went well Appropriate assignments Not feeling stressed Not feeling like you couldn t get things done in a timely manner Well supported People there to help Peers with good attitudes Able to take a break and lunch Able to teach families Received the resources form the house you requested Orange Busy assignment but received the help needed Overall busy and unorganized Some support but needed more Assignment busy and you don t have the supplies you need Chaotic and cannot catch up Road trip, assignment changes but received the help Had to change assignments during the shift Changes in patient condition NICU: Staff Definitions Red Super busy with no help Inappropriate assignments Leave work feeling over whelmed Entire unit busy, you know but there is nothing that can be done No support from the people you work with Assignment unsafe Staff not flexible House takes your resources away and creates less than ideal assignments/admit plan Stupid busy phones ringing off the hook Staff with bad attitudes Qualitative Scoring IS YOUR UNIT..... GREEN: Routine risk/stress level within normal variability met by daily operations YELLOW: Minimal risk/stress level with some variability met by minor operational adjustments ORANGE: Moderate risk/stress level with high level of variability, predicted or unanticipated that require considerable number of interventions and support RED: High risk/stress level with a high amount of variability predicted or unanticipated, that require a large amount of intervention and support but very challenging to meet. 12

13 System Level Qualitative Data Can see the entire day in 4 hour blocks Microsystem Stress: Qualitative Capturing Impact of Prolonged Stress on Staff Initial Testing Unit staff used colors denote their stress level for the day 4 level color scale utilized Staff defined what each color represented Expanded separate rating process by charge nurses Correlation found between charge nurse and aggregate staff ratings Microsystem Stress: Qualitative Capturing Impact of Prolonged Stress on Staff Current Process Charge nurses determine overall color rating each shift with input from staff and key roles on their unit Rating is entered into automated system every 4 hours and comment entered if rated orange or red Comments provide information for resource allocation Comments also give insight into why the unit feels stressed Shift and aggregate data is utilized for shift decisions and trending 13

14 What did we learn? BUILDING A SYSTEM Global Aim Develop a system to identify, mitigate and predict microsystem stress in order to prevent serious harm and other undesirable outcomes. Mitigate KEY Gray box = completed intervention Green box = what we re working on right now White box = future work 14

15 Team Name: Stressed Microsystems Team Date: September 14, 2015 Revision: 11 System Level Key Diagram Global Aim Develop a system to identify, mitigate and predict microsystem stress in order to prevent serious harm (and other undesirable outcomes). Primary Key Drivers Right factors (quantitative* and qualitative) are identified, validated, then utilized Timely access to the right data representing right factors Effective data analysis, review and data driven decisions Roles and processes for management and decisionmaking are clear Sub Projects Identification and validation of quantitative factors Volume Staffing Patient Acuity Identification and validation of quantitative factors Duration Stressed System* Identification and validation of qualitative factors Assessment of stress level by nursing Appropriate oversight and support by leadership Mitigation and ion Strategies KEY Gray box = completed intervention Green box = what we re working on right now White box = future work Show me the numbers! QUANTITATIVE FACTORS Microsystem Stress: Quantitative Microsystem Quantitative Daily Indicator Data - Reviewed published evidence - Validated relationship between indicators and harm - Indicators Actual and budgeted Average Daily Census (ADC) and percent occupancy Average actual Nursing Hours Per Patient Day (NHPPD) to budget Operational vacancy rate - Medical Leave of Absence (MLOA), orientation, hired and waiting for boards, posted and not yet hired Percent of float staff used Multiple sites of care 15

16 Updated List of or Variables Variable Periodicity CBDI Variable NICU Variable SRU Hours (RNs) Monthly X X Location Daily X X Percent Occupancy Daily X X NHPPD Hours X X Number of International Patient - Estimated Monthly X BMT New US Referral Monthly X BMT Num Chemo Doses Monthly X ONC Active Phase I Monthly X *Note: data sources, periodicity, and assumptions subject to change based on final model. Current data sources used as they contained historical data Microsystem Stress: Staffing Pick correct shift Add requests for needed staff Microsystem Stress: Staffing NHPPD 16

17 So now what? MITIGATION ESCALATION AND PREDICTION Microsystem Stress Report B4 NICU % % 88.5% % 9.0% % % 7 1.4% 4.8% 0.0% 4.8% Inpatient Unit Level I Interventions Mitigate Green Yellow Orange Red Attend bed huddle and Safety meeting. Match clinical resources to patient acuity and care needs. Offer any additional staff to the house. Continue with standard unit practices. & plan for admissions, discharges, and other flow factors today & looking forward. Smooth resources & post shifts not at core and also ask clinical staff and standby to pick up extra shifts based on volume. D/C patients that meet criteria in a timely manner. operational vacancy and staffing impact short term and long term. Strategize for increased RN hiring and orientation for large numbers of open positions. Utilize creative methodologies that expand beyond the unit. Assess available clinical resources and ability to care for patients based on acuity and care needs. Ask available current staff to work additional 4 hours Ask staff to work extra for defined shift with resource need. Ask available current staff to work an additional 4 hours. Request appropriate SRU/float staff for support such as RN, PCA, HUC, and Sitter. Evaluate the need to move support roles into charge or the direct care role. Unit level clinical and medical operational leaders to work on screening admissions and patient placement in collaboration with flow coordinators/mps lead. Make AVP aware of staffing and unit operations. Increase leadership rounding. Evaluate need to Evaluate move the need manager to cancel OPT/Education into if resource needs are not satisfactorily met. charge or direct care roll Evaluate the need to move a manager into charge or direct care role. Evaluate the ability to adjust Assignment with Preceptor/Orientee for Phase IV orientees close to completing orientation. Temporarily increase staff FTE as open positions filled Evaluate the need to cancel unit meetings or cancel staff attendance to department and division meetings. Evaluate the need for additional support from Pastoral services or other resources Consider purchasing food for staff. Evaluate the need for Organizational Support if Ongoing Orange. Unit level clinical and medical operational leaders discuss/determine need to reschedule pre-admissions and/or defer pts. Unit level clinical and medical operational leaders discuss ability to stop admissions and/or transferring patients to another facility. Evaluate the need for the Director to take charge/support role or continue with unit leadership activities to address unit operations. All hands on deck and attending meetings and other activities based on patient care needs and safety being met. All meetings and other non clinical activities cancelled and resources reassigned 17

18 Inpatient Unit Level II Interventions Mitigate Green Yellow Orange Red Maintain current processes with distribution of SRU/Float Resources. Consider microsystems that have been Include AVP/VP in discussion around Implement all applicable interventions stressed for over a week in distribution support for unit microsystem. denoted at Orange level. of resources. Evaluate the ability to partner with another unit with similar competency and has a lower volume or more positive operational vacancy. Evaluate the need to pre-assign some Evaluate the need to increase RN and SRU resources to promote consistency in Evaluate support and decrease the need staffing gap. Increase Month s Team support. for a special pay program based on Evaluate the need for a special pay prediction of program based on prediction of operational operational vacancy and longer term staffing vacancy gaps. and longer term staffing Support manager gaps. and educators working extra clinical shifts. Allied Health resources permanently related to new trends in ADC. Implement if appropriate. Evaluate the ability to cancel or hold off on accepting Destination and Tertiary Patients depending on clinical need, impact on program, etc. Evaluate the need for the use of Supplemental staff. Post positions if needed. Provide support to providers to assist with rounding and other clinical work. Dashboard Analysis Average Weekly Occupancy 13 units: Average ADC over budget ADC 7 units: >85% Occupancy 5 units: >90% Occupancy Average Nursing Hours per Patient Day (NHPPD) 7 units: Overstaffed by >5% 7 units: Understaffed by >5% 4 units: Within target range = GOAL Operational Vacancy Rate 5 units: >10% vacancy rate Float Use 6 units: >10% Decreasing over time as new hires leave orientation 2 units <12 beds Qualitative 3 units: >10% of shifts rated orange or red How are we using this information? Guides drill-downs into the data, why are the number high or low and do we have opportunity? Initiative around sitter use Mitigate Supports responding to trended data: Increase and/or reissuing RN FTEs Increase SRU RNs preassigned to an area Implement a knowledge bonus Utilize in decision making around distribution of resources from SRU Helps to predict intervention needs and explain current state Trended data helps to show duration 18

19 Summary of Data/Analytics 1. Performed statistical analysis to inform what measures might lead to harm (tested with CBDI/NICU) 2. Operationalized a microsystem stress measure that could be collected and sustained in the inpatient setting (nursing) (informed by PDAS cycles in CBDI/NICU) 3. Built a patient services operations system to collect and feed back the data (used for various nursing processes to ensure use). Incorporate PMRS dashboard reporting into PS system to help inpatient units mitigate. 4. Using SPC and empirical analysis to see if correlation exists between harm+concerns+803-safe calls (composite measure of not good care ) 5. Future: determine if statistical analysis would show relationships with stress duration and outcome to help us be able to predict. Microsystem Dashboard CONCEPT Microsystem Outcomes Composite Measure Microsystem Key Processes (Nursing) Capacity Demand DRAFT Some measures are not completely operationalized. Measures are owned by various groups. Harm & Stress - TCC Time Period of Stress Data Special Cause Last Updated 3/9/2015 by A. Anneken, James M. Anderson Center for Health Systems Excellence 19

20 Summary of Learnings Both quantitative and qualitative metrics are helpful in identifying unit and system level stress Standardized mitigation and escalation strategies expedite decision making and execution of interventions Examination of trending data supports prediction and early detection of stressed systems Next Steps Incorporate year to date data into the report Consistently review and understand weekly trended data Quantitative and qualitative data utilized in decision making and resource allocation Spread to other mesosystems beyond inpatient Transition to utilizing new Daily Microsystem Report Questions? 20