Improving Emergency Medicine Program: Implementation & Sustainability

1. National Emergency Medicine Programme Implementation Update November 2012 These slides provide an overview of: ED and LIU pathways (slide 2) ED patient pathway developments recommended in the EMP Report 2012 and First Steps document. Emphasis is on local adaptation of model to meet patient needs (slides 3 to 5) EMP Implementation Approach (slide 6, 10, 11) Clinical Microsystems (slides 7, 8, 9) Diagram illustrating Emergency Care as a complex adaptive system (slide 12) Factors to consider in implementing large scale health system change (slides 13, 14) Path ahead (slide 15) Cut and paste, amend and adapt as appropriate to your ED team

2. Patient Pathways – ED and LIUs ED Arrival Triage Seen by treating clinician Disposition Decision Registration S/B Admitting Team ED Pathway of care Completion Admitting team ED Departure GP Access to Diagnostics Rapid Access OPD Specialty Assessment/Admission Units LIU Pathway of care Registration ED Arrival Seen by treating clinician Disposition Decision Emergency Medicine Programme

3. Arrival to seen by treating clinician Registration Triage Advanced Triage Arrival Seen by treating clinician Monitoring Protocol Streaming Ambulance Handover RAT Mini-registration Work-redesign • Assess peak demand • Staffing resource • Share protocols • MTS only • Standardised triage • Demand capacity analysis • Monitor effectiveness • Pain assessment • Infection Prevention & Control ANP streamFast track • ECG • Front-load blood tests • Supply analgesia • Mental Health Decision Tool • MTD Assessment • Frail Elderly Evidence Based Pathway of care EMP Report 2012 Chapter 19 & references

4. Patient Pathway Review with results Seen by treating clinician Monitoring Protocol Disposition Decision ANP stream Process Efficiency Initiatives Access to Diagnostics Medical Workforce Protocol for patients who leave before completion of treatment Clinical Guidelines Sharing effective practice ConditionSpecific Pathways Emergency Medicine Programme

5. Patient Pathway CDU protocols Direct ward admission protocol Process efficiency initiatives Data captureDiagnostic coding Disposition Decision ED Departure S/B Admitting Team Completion Admitting team Assessment Transition of care protocol Bed management Emergency Medicine Programme

6. EMP Implementation Approach Emergency Care System Safe, high-quality reliable, resilient patient care and clinical teams How do we make the changehappenand sustain improvement? What changes are needed to implement the EMP in our ED? EMP First Steps Clinical Microsystems

7. Sustainable Improvement Triangle Better OutcomePatient, Population(health status, patient experience, illness burden) Better ProfessionalDevelopment(competence, pride, joy) Everyone Better SystemPerformance(quality, safety, value) Batalden Davidoff Sustainable Improvement Triangle: Sustainable efforts in real settings require inextricable linkages “The combined and unceasing efforts of everyone - health care professionals, patients and their families, researches, payers, planners, educators – to make the changes that will lead to bettter pateint outcomes, better system performance and better professional development (learning new knowledge, skills and values).” Emergency Medicine Programme

8. What are Clinical Microsystems? Patient Provider Information The clinical microsystem is where care is “made”. It is at this level that quality, safety, reliability, efficiency and innovation are created along with staff morale and the patient experience. All other components of the health system exist to support the clinical microsystem. www.clinicalmicrosystem.org for further information and resources.

9. Dartmouth Microsystems Improvement Curriculum for Emergency Departments Steps Lead Team Assessment Diagnosis Treatment Follow-up Activities Set up Team Set up ED COG Decide way of working Set objectives Baseline Analysis- ED Attendance Data- ED Profile Analysis- Purpose definition- Survey patients, staff, team skills, activity; Process Mapping Patterns Analysis Demand/capacity planning Strengths/weakness analysis Lean/Six Sigma approaches Value stream mapping Prioritisation matrix Implementation plan Plan-Do-Study-Act Lean 5-S Other improvement tools Lessons Learned Use ED COG for Continuous Improvement Cycle

10. Implementation Support Approach Strengthening Governance, with defined roles and meetings structure Standard metrics and data base lining Knowledge & Ideas Training in quality improvement including microsystems, effective meetings, process improvement etc. • Stan Detailed, on -the-job coaching to train entire ED team and embed approach within unit Continuous Quality Improvement Context Outcomes Actions Knowledge, best practise and experiencesharing through website, meetings and seminars

11. Putting it all together ClinicalMicrosystemsImprovement Approach Achieving EMP aims for patients, staff and the health system Ongoing improvement Patient participation and feedback First Steps EMP Report 2012 ECN Infrastructure, workforce, Intelligence, resouces. ED Clinical Operational Groups, EMP Implementation Teams and Programme Support EMP Outcomes Measurement(using baseline data) National Initiatives (e.g. datasets, EDIS, Emergency Care Networks) Implementation support from hospital, region, HSE, SDU, DOH Building a foundation for sustained improvement

12. A Complex Adaptive System Ambulance service • Patients • Volume of demand • Time distribution of demand • Complexity of casemix • Acuity of casemix • Age profile • Patient perceptions & preferences Hospitals for escalating levels of care • ED • Workforce • Nursing, medical, others • Skill-mix • Agency/locums/overtime etc. • Quality of care • Evidence based, cost-effective care • Patient experience • Process efficiency • Patient outcomes, safety, risks • ED infrastructure to match demand • Access to diagnostics for ED discharges • CDU care reducing LOS Linked Emergency Care Network Units System Intelligence Data capture – EDIS Outcomes measurement Process measurement Cost capture, allocation and management Primary & Community care • Acute Hospital • Supporting on-site specialties and services • Work practices • Access to diagnostics • In-patient bed capacity , utilisation & access

13. Improving a Complex Adaptive System Improvement science learning points: Create the conditions for improvement and change Try not to increase the chaos in the system e.g. by introducing changes that are not aligned with overarching goals Command and control approaches are less likely to lead to sustainable change – flexibility, small tests of change and a ground-up approach are more likely to be effective Actions: Set strategic goals and align improvement to the goals Provide essential infrastructure to support improvement Track priorities Test changes at local level Spread and sustain improvement Get everyone involved Ensure accountability

14. Organising Quality Health Care These challenges exist at ED, hospital, network and national level. *Bate P et al. Organising for quality: The improvement journeys of hospitals in Europe and the United States. Radcliffe Pub 2008.

15. The Path Ahead National Level: HIQA Tallaght Report Implementation EMP - sharing effective practice; models of care; supporting implementation teams SDU / DOH/HSE Creating the environment for implementation – capacity, focus, priority Hospital and regional support Workforce issues within emergency care Local level (customise as appropriate)