Linda K. Kosnik, RN, MSN, ANP, CEN Chief Nursing Officer,Overlook Hospital Atlantic Health System

1. 2003 Illinois College of Emergency Physicians “On Our Watch”Practical Tools for Collaboratively Managing Hospital Demand CapacityJanuary 10, 2003Chicago Linda K. Kosnik, RN, MSN, ANP, CEN Chief Nursing Officer,Overlook Hospital Atlantic Health System

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.

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.

4. 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.

5. At the Atlantic Health System we are exploring how Collaboration/CRM can be operationalized with the outcomes of efficient Demand Capacity Management • CRM’s 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

6. 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.

7. 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

8. Patient Satisfaction Medical Outcomes Quality of Life Cost A Microsystem Awakes • We have used Gene Nelson’s 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” Espinosa, 2002

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)

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

11. Field Notes : Stages In Our AHS Experience • Self Aware Microsystem (m) • Like microsystems (m+m+m…) • Unlike microsystems (m+m+m…) • Microsystems to Macrosystems (m+ m +m… +M) • Like Macrosystems (M+M+M…) • Macrosystems to Unlike Macrosystems (M+M+M…) Kosnik and Espinosa, 2002

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

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

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

16. ED ED ED ED ED ED Stage Two: Like Microsystems Collaborate Overlook ED • IHI Waits and Delays For the Emergency Department Collaboratives • Emergency Physicians Associates Collaboratives • Patient Satisfaction Lab

17. 1998 and 1999The IHI Collaboratives • 1998 Collaborative 31Teams 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! • 1999 Collaborative 19 Teams Locations:Australia, CA, FL, IL, MD, MO, NC, NY, OH, PA, TN, TX, UT, WV Total Patients Per Year =848,000 Results: 80% reached “significant improvement” over a 9 month period

18. ED Median Total Length of StayOak Ridge Methodist Medical Center Week

19. ED Median Door to Doctor TimeOak Ridge Methodist Medical Center Week

20. EPA Collaborative ExampleLike Microsystem to Like Microsystem) Collaboration(m+m+m…)Example:Multi-hospital ED Multi-year Ongoing Collaboratives:

21. A P A P S D S D Supports 1. Calls 2. Listserv / E-mail 3. Visits 4. Monthly Reports (10th of each month starting in June 00) 2000 to 2003EPA/Team Health Collaborative Select Topic Identify/Select Participants Prework Handbook Set Aims and Goals Summarize Changes Learning Session 1 LS2 LS3 5/00 9/00 5/01 Key: P = Plan D = Do S = Study A = Act

22. Average # Minutes To Transfer From EDRobert Wood Johnson University Hospital

23. Average Time To Transfer From ED to ICU/Telemetry - Massena Memorial

24. Median Times for All ED PatientsGood Samaritan Hospital Total Length of Stay Faster Care

25. Lessons Learned: Be FlexibleSupport 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.

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

27. ED Inpatient Units ICU OR/RR Envir Inpatient Units Transport Stage three: Unlike Microsystems Collaborate(m+m+m+m…) Radiology Lab • Reducing Xray Turnaround Times. • Admission Cycle Time • Safety Summit M Medical Staff Dietary Case Management Pharmacy Management

28. Example:Reducing Admission cycle time(m+m+m+m…)

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.

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 satisfaction—and reducing ED efficiencies—but 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

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

32. Admission Cycle Time • 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

33. Benefits of Decreasing Admission Cycle Time • Benefits • Reduce and/or eliminate holding • Reduce and/or eliminate divert • Budget neutral solution • Improved patient/staff/physician satisfaction

34. Admission Cycle Time

35. Average Admission Cycle Time in Minutes

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)

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

38. Example: Matching Capacity to Demand Management To Drive Improvements In Flow(m+ m +m… +M)

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 practices”across microsystem and macrosystems • Decreased variation in practice patterns • Increased customer confidence

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

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

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

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

44. Green

45. Green • What does a good day look like?

46. Green • Interventions

47. Yellow

48. Yellow • Early triggers • What can we identify and manage early or on a regular basis?

49. Interventions Yellow

50. Orange