Kosnik 2003 1 2003 Illinois College of Emergency Physicians On Our Watch Practical Tools for Collaboratively Managing Hospital Demand Capacity January 10, 2003 Chicago Linda K. Kosnik, RN, MSN, ANP, CEN Chief Nursing Officer,Overlook Hospital Atlantic Health System
Kosnik 2003 2 Objectives This presentation will demonstrate how matching of stress loads on systems, to capacity in dynamic processes creates more highly reliable systems and cultures. The concepts of Crew Resource Management which are usually defined at a team level can be applied at higher orders of complexity, so that microsystems within macrosystems communicate and collaborate effectively.
Kosnik 2003 3 Objectives The resulting processes can be defined and measured based on specific criteria, which interpret the conditions, loads and stressors on the system. For each criteria interventions can be developed to move, compensate and recover design capacity. In this model a system of color-coded grids has proven to be effective and replicable in creating a collaborative culture that promotes an environment for safe and efficient healthcare practices as well as improved outcomes.
In Aviation Safety…The Student of Collaborative Principles will find parallels in Crew Resource Management (CRM) CRM is a communication methodology focusing on team-centered decision-making systems which was developed by the aviation industry in 1979 to reduce human error in air crashes. When applied to healthcare, the communication space of health care practitioners caring for critically ill patients can be viewed as resembling that of an aircrew engaged in complex flight operations. Team-centered decision making systems enables teams to perform more efficiently.
At the Atlantic Health System we are exploring how Collaboration/CRM can be operationalized with the outcomes of efficient Demand Capacity Management CRMs primary building blocks include the use of –Backup systems –Team communication and coordination –Adequate briefings, Availability and use of resources –Leadership and adequate supervision –System Knowledge –Personal readiness –Planning –Correction of known problems and issues –Management support
CRM and Communication In CRM team building progresses in an open communication environment All team members are able to speak freely with equal acceptance of ideas Conflict resolution is achieved through a democratic process Execution is a complex matrix of team monitoring, cross-checks, workload management, vigilance, and automation management.
CRM/Collaboration Tracks with a Culture of Safety…. The concept alignment process in the CRM model provides a measurable process to affect human factors issues If consistently used, the model –Facilitates the voicing of innovative ideas –Holds all team members accountable –Helps the team develop a sense of organizational attachment –Supports the development of positive team behaviors –Promotes an awareness of personal limitations –Reduces decision-making requirement during emergencies
Kosnik 2003 8 A Microsystem Awakes We have used Gene Nelsons Quality Value Compass since 1997 An approach to manage and improve quality and value Focused on testing the effects of changes in care processes Led us down the path to microsystem awareness Medical Cost Patient Satisfaction Quality of Life Outcomes Espinosa, 2002
Kosnik 2003 9 A Mini Microsystems Review The small, functional, front-line units that provide most health care to most people. Essential building blocks The place were patients and providers meet The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. (Nelson et al,2002)
Kosnik 2003 10 A Self Aware Microsystem Cultural Change No longer simply a department but a business unit of a larger system. A move from collaborating within a department to being fellow members of an enterprise whose goal was to deliver excellent clinical care. Espinosa, 2002
Kosnik 2003 11 Field Notes : Stages In Our AHS Experience 1.Self Aware Microsystem (m) 2.Like microsystems (m+m+m…) 3.Unlike microsystems (m+m+m…) 4.Microsystems to Macrosystems (m+ m +m… +M) 5.Like Macrosystems (M+M+M…) 6.Macrosystems to Unlike Macrosystems (M+M+M…) Kosnik and Espinosa, 2002
Kosnik 2003 12 Stage One: A Microsystem Becomes self aware Satisfaction Summit Reducing Waits and Delays Initiative Use of real-time data Use of Storytelling Appreciative Inquiry Actualization of Staff Ideas Overlook ED
Kosnik 2003 13 Use Real-time Data Real-time data is helpful in improving ED patient satisfaction. In our ED, our patient tracking system provides real- time display of 8 critical ED processes, displayed on one screen, as run charts. Goal lines are set for these processes, and the data is displayed as 15 minutes averages of the processes, showing the current and last three hours of performance. Interventions are based on three or more consecutive breaches of identified goals
Kosnik 2003 15 Exciting New Infrastructural Tools Emerged New emphasis on Appreciative Inquiry or Appreciative Management –We analyze not only at outliers in the area of poor performance, but also outliers in the area of outstanding performance! –We celebrate cooperation with the larger system, and look for areas to improve cooperation with the larger system. Live Stories from patients at Microsystem meetings (1999 to present) Patient Safety Laboratory (2000) –We developed a patient safety laboratory, with an associated conference room –A video camera feeds to a television and VCR in the conference room –A suite of rooms was adapted for use as a mock ED, as well as for other mock re-enactment purposes Live Stories from Private Attendings at ED Microsystem Meetings (2000 to Present) –Now a regular feature of our meetings –Representing stories of what went well and what did not –Helps to foster cooperation and to role-model openness
Kosnik 2003 16 Stage Two: Like Microsystems Collaborate IHI Waits and Delays For the Emergency Department Collaboratives Emergency Physicians Associates Collaboratives Patient Satisfaction Lab Overlook ED ED
Kosnik 2003 17 1998 and 1999 The IHI Collaboratives n 1998 Collaborative 31Teams 31Teams Locations: AL, CT, CA, FL, GA, IL, KY, MA, MD, NC, NJ, OH, TN, TX Locations: AL, CT, CA, FL, GA, IL, KY, MA, MD, NC, NJ, OH, TN, TX Total Patients Per Year = 1,247,500 Results: 84% reached significant improvement over a 9 month period! Total Patients Per Year = 1,247,500 Results: 84% reached significant improvement over a 9 month period! n 1999 Collaborative 19 Teams 19 Teams Locations: Australia, CA, FL, IL, MD, MO, NC, NY, OH, PA, TN, TX, UT, WV Locations: Australia, CA, FL, IL, MD, MO, NC, NY, OH, PA, TN, TX, UT, WV Total Patients Per Year =848,000 Total Patients Per Year =848,000 Results: 80% reached significant improvement over a 9 month period Results: 80% reached significant improvement over a 9 month period
Kosnik 2003 18 ED Median Total Length of Stay Oak Ridge Methodist Medical Center Week
Kosnik 2003 19 Week ED Median Door to Doctor Time Oak Ridge Methodist Medical Center
Kosnik 2003 20 EPA Collaborative Example Like Microsystem to Like Microsystem) Collaboration (m+m+m…) Example: Multi-hospital ED Multi-year Ongoing Collaboratives:
2000 to 2003 EPA/Team Health Collaborative Select Topic Summarize Changes Identify/Select Participants Prework Handbook Supports 1. Calls 2. Listserv / E-mail 3. Visits 4. Monthly Reports (10th of each month starting in June 00) Learning Session 1 LS2 LS3 5/00 9/00 5/01 Set Aims and Goals A P S D Key: P = Plan D = Do S = Study A = Act A P S D
Kosnik 2003 22 Average # Minutes To Transfer From ED Robert Wood Johnson University Hospital
Kosnik 2003 23 Average Time To Transfer From ED to ICU/Telemetry - Massena Memorial
Kosnik 2003 24 Median Times for All ED Patients Good Samaritan Hospital Total Length of Stay Faster Care
Lessons Learned: Be Flexible Support Whatever Clinical Process Improvements are Needed Time to Thrombolytic Treatment/AMI and CVA Time to Antibiotic Treatment in Pneumonia Patients Time to Antibiotic Treatment in Neutropenic Patients Pain Management Etc.
Kosnik 2003 26 2001 to 2003 Collaborative: New Directions Safety Microsystem Development Storytelling/Narrative Techniques Appreciative Inquiry Matching Capacity to Demand Management To Drive Improvements In Flow
Kosnik 2003 27 Stage three: Unlike Microsystems Collaborate (m+m+m+m…) Reducing Xray Turnaround Times. Admission Cycle Time Safety Summit M ED Inpatient Units ICU OR/RR Inpatient Units Envir Transport Lab Dietary Medical Staff Pharmacy Case Management Radiology Management
Example: Reducing Admission cycle time ( m+m+m+m…)
Kosnik 2003 29 Reducing Admission Cycle Time Where top-down support is essential: Reducing Admission Cycle Time! Patients awaiting admission decrease the functional capacity of the ED. Efforts to decrease admission cycle time call for the very best in senior leadership. Barriers include a sense on the part of many inpatient units that ED admissions are additional work. In fairness, the ED often does not realize that a given floor may be in the process of receiving multiple simultaneous admissions. Delays in getting beds cleaned and in getting and giving report often complicate matters enormously.
Kosnik 2003 30 Creating Interdepartmental Collaboration to Reduce Admission Cycle Time. Use the patient satisfaction survey as a tool to unite perceptions of the stakeholders. Prolonged admission cycle times contribute not only to decreased ED satisfactionand reducing ED efficienciesbut also to decreased inpatient scores. Identify barriers together Fair, open, even-handed analysis and discussion of data. Data collection will predictable show that a percentage of the burden of delay is on the ED side. Give credit to all stakeholders for improvements seen! Set a goal of less than 60 minutes….ideally, cycle times of an hour or less from the time that the decision is made to admit the patient, to the time that the patient is admitted, are possible! Demonstrate Benefits and Rewards of New Systems Constantly Re-evaluate
Kosnik 2003 31 Admission Cycle Time Interventions –Czarina of bed control concept –Bed control brought under the ED –Eliminating discharge holding –Decentralized registration and housekeeping –Collaborative Interdepartmental/ Interdisciplinary team approach –Standardized documentation tool
Kosnik 2003 32 Interventions –Creating a push-pull system –Real-time data collection and monitoring –Timely feedback –Living flowcharting –Never underestimate the value of communication –The non-verbal report –Demand management Admission Cycle Time
Kosnik 2003 35 Average Admission Cycle Time in Minutes
Kosnik 2003 36 Patient Satisfaction Lab* Create a permanent designated space for a Patient Satisfaction Lab –Signage –Bi-weekly review of surveys and action plans with senior management –Staff and management handling of surveys –Individualized attention (*Espinosa, Kosnik 1999)
Kosnik 2003 37 Stage Four: Microsystems Collaborating with and within the Macrosystem (m+ m +m… +M) A Safety Summit and Mislabeled Lab Specimens Overlook Hospital Demand Capacity Management System M
Kosnik 2003 38 Example: Matching Capacity to Demand Management To Drive Improvements In Flow (m+ m +m… +M)
Kosnik 2003 39 Impact of Robust Demand Capacity Management Systems Reduce incidents of overload –Manifested by divert/bypass –Inpatient services melt-down The ability to diffuse best practicesacross microsystem and macrosystems Decreased variation in practice patterns Increased customer confidence
Kosnik 2003 40 Impact of Robust Demand Capacity Management Systems A system that is more stable and reliable facilitates safer systems –Monitoring, prevention and mitigation of stress loads returns control to the system Receptor site availability Improved Staffing ratios Supplies accessible when needed –Uses human factor principles
Kosnik 2003 41 Robust Demand Capacity Management Systems Uses human factors principles –Improve information access –Decrease reliance on vigilance –Reduce handoffs –Increase feedback –Automate carefully –Avoid reliance on memory –Simplifies –Standardizes –Uses constraints and forcing functions –Uses protocols and checklist wisely
Kosnik 2003 42 Robust Demand Capacity Management Systems Customer Satisfaction –Waits and delays Staff Satisfaction –Recruitment and retention Communication Collaboration –Use of Crew Resource Management Skills –Healthcare providers (Out-Patient/Emergency Department/In-Patient/Support Services) –Administration and leadership Integrated approach to resource management
Kosnik 2003 43 How to create more reliable, sensible and adaptable systems to meet those goals? Better understand of stress loads on systems, system states and looked at creating more highly reliable systems and cultures (Weick) This is Crew Resource Management at a higher order of complexity (Reason, Brown) We defined states, related to criteria of conditions, loads and stressors, and developed interventions to move, compensate and recover design capacity The states were given colors in relation to the conditions, loads and stressors
Kosnik 2003 59 Forms, Grids and Flow Admission Cycle Time Data Collection Form Admission Cycle Time Flow Chart ICU Decision Flow Demand Capacity Grids –Emergency Department
Kosnik 2003 60 But Does It Really Work? Retention Rate= 90% Admission Cycle Time A new collaborative approach to Demand/Capacity decision making Time since last episode of –Critical Care Divert –Full Divert
Kosnik 2003 61 Days Since Last Divert of Any Kind
Kosnik 2003 63 Stage Five: Like Macrosystems (M+M+M…) Demand Capacity Management Idealized Design for Falls Management Service Lines M M M M
Kosnik 2003 64 Example: Matching Capacity to Demand Management Among Macrosystems (M+M+M…)
Kosnik 2003 65 Advanced Spread of These Principles: Creating more robust micro-systems/components/departments Laboratory Radiology Respiratory Case Management/Social Work Environmental Dietary Pharmacy Security Engineering Purchasing/Materials Management Information Systems Volunteer Services/ Transport Services Medical Records Patient Representatives/ Pastoral Care MICU/EMS Radiation Therapy Peri-operative services Post-Acute
Kosnik 2003 68 Advanced interventions under current design Advanced third-generation discharge program with more idealized coordination with case management Advanced system-wide on-call systems Advanced system-wide staffing system
Kosnik 2003 69 The Biology of Cooperation Some components are better suited to support specific components, as well as the macro-org –(i.e. Environmental can provide support to dietary but cannot provide support for transport) There appears to be a hierarchy of impact (temporally) –First service to be impacted is tends to be transport (getting patients to services or services to patients) The biology of multi-organ failure: –The ability of services to provide support significantly decreases with the number of services in orange or red
Kosnik 2003 70 Stage Six: Unlike Macrosystems Collaborating Together (M+M+M…) M R N Rehab Home Care Nursing Homes Community EMS/Transport
Kosnik 2003 71 Examples: Macrosystems Everywhere (M+M+M…) Cardiac, Neuroscience, Safety, Satisfaction Initiatives Disaster Plans Communication between and to –Nursing Home Reports –Home Care Reports –Doctors offices
Kosnik 2003 72 Keys to Success Building Trust Goal is embedded predisposition to trust, Identify similar characteristic and goals Experiences of reciprocity Achieved through Microsystem management meeting Retreats Collaborative Initiatives (MIC, Internal idealized design Summits Demand/capacity collaborative Appreciative inquiry.
Kosnik 2003 73 Keys to Success Mitigate constraints/barriers within microsystem and between microsystems Demand/capacity Management Operations Control Center (OCS) Micro/macro work Internal collaboratives Idealized designs Visual technology to reduce the Fog of War Biology of cooperation
Kosnik 2003 74 Keys to Success Facilitate Reciprocal Relationships: Willingness and openness to reciprocal action Storytelling Alignment of goals and strategies Appreciative inquiry Flu season story as the precipitating incident ongoing collaborative work in demand capacity throughout the system Operations Control Center (OCS)
Kosnik 2003 75 Keys to Success Create a common language: Common vocabulary and syntax Encourage interactions and conversations Work collaboratively to solve problems Frame all activities as shared Create a common language for shared information and resources across boundaries to solve common problems OCS A common pain scale/degrees for the economy for demand/capacity mismatch. Supply a framework for collaborative sharing Linguafranca –notion of a microsystem/macrosystem social economy where people are borrowing/sharing energy/money/social relationships. Demand/Capacity load identification (example=color coding)
Kosnik 2003 76 The United Nations of Micro/Macrosystems Use United Nations thinking to Create a United Microsystems (UM) to solve problems Demand/Capacity Issues Using this metaphor the UM members need to trade with each other. Our experience defines stress states using a color coding system. These are definitions that work for us and may be similar to what you will define but it requires the collaboration and participation of the UM I have created a grid or process (a means for microsystems to come together and collaborative) by which this can be achieved. To support participation there may be a FTA (free trade agreement). If you do not participate the system will levy a tax for not collaborating and force those microsystems to find support from outside.
Kosnik 2003 77 Future Steps Future steps---- Commonwealth funds….virtual safety program which will teach people how to drive the OCS Creating a symbolic language for the equations M=macrosystem, m=microsystem, macro\macro collaboration Further integration of CRM tools to promote collaboration Measurement of the impact-flavor of the operational definitions. Promoting the economic implications of the approach. Example= The cost of inefficient demand capacity management. What are the rules that apply.