These presenters have nothing to disclose. Redesign the System: Improving Med/Surg Efficiencies and Patient Flow Amanda Stefancyk Oberlies, Pat Rutherford and Christine White Hospital Flow Professional Development Program November 2, 2016 Cambridge, MA
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, agreedupon 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 higherorder 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)
Findings Relationships shape the communication through which coordination occurs...
Nurses Case Managers Patient care: A coordination challenge Attending Physicians Nursing Assistants Patients Physical Therapists Social Workers Technicians Referring Physicians Administrators
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 relating for 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
Relational mapping 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 of current state WEAK RC MODERATE RC STRONG RC Workgroup 1 Workgroup 5 Workgroup 2 Workgroup 4 Workgroup 3 RC = Shared Goals, Shared Knowledge, Mutual Respect, Supported by Frequent, Timely, Accurate, Problem-Solving Communication 14
Example
RC matrix Ratings of Admin CC PCAs Phys PA&NP RNs ResTh R a t i n g s b y 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 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
Assessing current state Reporting back 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 MGH Amanda Stefancyk Oberlies PhD, MBA, RN, CENP Chief Executive Officer Organization 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
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 Staff generates idea Collaborative learning Small tests of change Spread 23
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 shared between 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 Always Complete Collaboration Strongly Satisfied 6 5 Before After 4 3 Never No Collaboration Strongly Dissatisfied 2 1 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Questions C. J. Baggs 1988
AJN TCAB Series (Sept 2008 - Aug 2009)
This presenter has nothing to disclose Redesign the system: A Comprehensive Approach to Caring for Hospitalized Medically Complex Patients Christine White MD, MAT Associate Professor-Hospital Medicine Cincinnati Children s Hospital Cincinnati, Ohio November 2, 2016 James Anderson Center for Health Systems Excellence
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 Neurologic impairment (ex: cerebral palsy, brain injury) Tracheostomy tube Gastrostomy tube
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
Our History/The Problem -Patients from CCC cohorted onto 1Hospital medicine (HM) team -Staffed by CCC attending (105 patients/year) -Other general HM patients also on team 2011 2013 Complex patients distributed amongst all 5 HM teams Remainder of neurologically impaired and technology dependent patients distributed among other 4 HM teams -Staffed by HM attendings (350 pts/year) Creation of New Complex Care Team 38
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
Outcomes: Discharge Efficiency Prior Work Physicians define medical criteria in EHR on admission Patient meets medicallyready 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 49
Consult Timeliness Frontline Staff Engagement Pharmacy Process Change How will this process apply to complex patients with unique discharge needs? 50
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
Increase the percentage of medically complex Key pediatric Drivers patients discharged within 2 hours of meeting medically ready criteria from 50% to 80% by September 1, 2014 Optimization of Team Structure Discharge Goal Identification Anticipation of Discharge Care Needs Staff Engagement in Discharge Preparedness Care Coordination
Run Chart Cohort Patients on Complex Care Team 54
Run Chart Cohort Patients on Complex Care Team Creation of Complex Care Admission Order Set 55
Complex Care Order Set 2013 Epic Systems Corporation. Used with permission. 56
Needs Assessment Tool Group Patients on Complex Care Team Creation of Complex Care Admission Order Set Weekly Multidisciplinary Care Coordination Rounds Medication Pathway 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 61 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
Nurse Feedback 62 Item Strongly disagree % (n) Disagree % (n) Undecided % (n) Agree % (n) Strongly agree % (n) More resources than before complex care team More comfortable providing care than before complex care 0% (0) 0% (0) 43% (10) 48% (11) 9% (2) 0% (0) 9% (2) 39% (9) 52% (12) 0% (0) Complex care team members are approachable and work well with other disciplines Have the appropriate amount of staff/resources to care for complex care patients 0% (0) 0% (0) 23% (5) 59% (13) 18% (4) 9% (2) 17% (4) 35% (8) 39% (9) 0% (0)
Resident Feedback 63 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.
Rounds Integration of Bedside Providers: RN led Rounds
Overall Aim 65 Standardize chronic care processes and multidisciplinary collaboration and communication
SMART Aim 66 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
RN/Respiratory (RT) led rounds
RN Script 68 Pt Name: Tracheostomy Unit AM Rounding Sheet Nursing 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! P74 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 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 Yellow 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%
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