Culture Change in Hospice Culture Change in Hospice of the Lakes: Multi-of the Lakes: Multi-

disciplinary to Inter-disciplinary to Inter-disciplinarydisciplinary

Descriptive Society Annual Meeting

September, 2008

Richard Heinrich, M.D., M.A.

Why is this topic important?Why is this topic important?

• When Keith asked me what I was working on at first I said I didn’t have anything to present, then after some reflection I thought about what I have been doing for the past 8 years.

• I would like your help in telling this story…• You are all resident experts in DP and all have

some organizational expertise….• So in each act what advice would give to the

Hospice leadership group?

An unfolding story in three An unfolding story in three actsacts

Multidisciplinary to Interdisciplinary Teams (teaming)

Act I: Nurse care manager model

Act II: Self managed care teams

Act III: Interdisciplinary care teams

Act IV: ??Trans-disciplinary or ???

BackgroundBackground

• Managed care and nursing 1980 to 2000• Hospice care: In the 1982 Tax Equity and Fiscal

Responsibility Act (TEFRA), Congress added a hospice benefit to the Medicare program. – Cost went from $1.2 B in 1995 to $8 B in 2005– Budget in the foreseeable future will not keep

pace with the tsunami of baby boomers, 76 million who will start to come of a certain age in 2011

• New buzz word is “affordable care’

What are we doing by doing What are we doing by doing that….?that….?

• Fragmented care as a hallmark of the evolution of the US care delivery non-system based upon individual choice– Disease management as a failure path to controlling costs, may

or may not improve quality of care• One approach to fragmentation is the concept of a primary care

“home” where primary care is staffed up to provide team based care to address fragmentation– ???? Questionable what outcomes will be achieved

• Congress wants value and affordable care– Little political courage in facing the clinical, operational and

financial incentives that it would take to provide a STEEEP care delivery system (safe, timely, effective, efficient, equitable and patient/family care delivery system

Hospice: a platform to provide Hospice: a platform to provide comprehensive patient/family comprehensive patient/family

centered carecentered care• Traditional hospice programs were

founded on a nurse case management model

• The team concept in hospice is poorly defined

Load versus HOL horsepowerLoad versus HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2001 Year 2005

Load versus HOL horsepowerLoad versus HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2006 Year 2008

Hospice of the Lakes Growth 2001- 2008

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HOL 2008 Year to Date

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Carrying Capacity: Census/FTE

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2008 Avg daily census

Three Acts in an unfolding Three Acts in an unfolding DramaDrama

Act I: Traditional Nurse Case Manager Model

Act II: Self-managed Teams

Act III: Inter-disciplinary Teams

Act IV: ??Trans-disciplinary???

Act I: Prior to 2003Act I: Prior to 2003

• Traditional Nurse Case Management Model

• Players

– Leadership and managers

– Nurses

– Social Workers

– Chaplains

– HHA, Volunteers

Evaluation, Outcomes and Evaluation, Outcomes and ProblemsProblems

• East and West Side Geographic division of patients

• Nurses owned the patient and decided on what services were necessary– Staff centered focus– No specific teams or working relationships

• Meetings were chaotic• Little supervision or accountability• Lack of respectful interpersonal relationships• Poor meeting hygiene

Advice to the hospice Advice to the hospice leadership group?leadership group?

Leadership and program Leadership and program changes as the end of Act Ichanges as the end of Act I

• New Leadership group begins in 2000-2001

• I became Medical Director in 2001

• New program director in 2001

• Census was in the 80s, patients were vended, program not serving the HP Medical Group nor patients

• HP Pursuing perfection initiative

The Pursuing Perfection The Pursuing Perfection ProjectProject

• ICI and the RWJ Foundation sponsored a nationally competitive grant among organizations committed to rapid cycle improvement of their healthcare delivery systems

• HealthPartners was one of 7 selected organizations in 2001 to improve their care delivery system.

• One of 7 projects at HPMG was to improve the quality of care delivered at end of life

Improving Organizational Capacity to Improving Organizational Capacity to provide State of the Art End-of-Life provide State of the Art End-of-Life

CareCare

Begin with the End in Begin with the End in MindMind

To implement organization-wide, perfectly coordinated, state-of-the-art end-of-life care that addresses pain and suffering!

Pursing Perfection: brewing concepts Pursing Perfection: brewing concepts of organizational care and of organizational care and

collaborationcollaboration• Rapid cycle change!!!!

• HP organizational map of care and strategy to bring about change

– Home based care

– Hospital based care

– Clinic based care

– Skilled nursing home based care

– Assisted Living based care

Addressing Pain and Suffering at the Addressing Pain and Suffering at the End of LifeEnd of Life

State-of-the-art end-of-life care encompasses: • a broad range of clinical practices, • patient and family- focused access to such care • STEEEP principles and • seamless organizational implementation across

venues of care.

End of life Care Goals of Treatment

• Self-determined end of life closure & care

• Comfortable dying (effective palliative treatment of symptoms and suffering)

• Safe dying

• Effective Grieving and coping

NHPCO Goals for Hospice Organizations

Promises to Patients and Promises to Patients and Families regarding End-of-Life Families regarding End-of-Life

CareCare You will know that 100% of HOL staff, HPMG & Clinics and

Hospital staff are able to provide state-of-the-art EOL Care.

You and your family will be satisfied with HOL enrollment and follow-up care

You and your family's goals of treatment will be met

You will be satisfied with the control of your symptoms and suffering at end of life

You and your family members will be satisfied with your end of life experience, given your medical circumstances

Organizational Health Care Organizational Health Care Design ElementsDesign Elements

• Prepared Practice Teams

• Activated and informed patients and families

• Health Information Support

Prepared Practice Teams

Activated Informed Patients

Health Information

Support

Venues

Home

Hospital

Clinic

Nursing Home

Goals of Treatment

Epic Web:

Plan of Care

Advance Directive

Ethical Will

Goals of Care

Self Determined EOL Closure

Safe and Comfortable Dying

Effective Bereavement

Expanding Options at EOL

Health Care Delivery Design

Staging of the End of Life Staging of the End of Life Care ProjectCare Project

Expert Panel Review

• End of Life Care Content

• Goals and staging of the project

– Stage I: Internal Hospice Program Focus

– Stage II: Organizational Focus

– Stage III: Membership Focus

Stage I: Internal Focus Stage I: Internal Focus Hospice of the LakesHospice of the Lakes

Health Information Support• Comfort Assessment

– Standardize Administration– Develop Report format for IDG rounds and

EPIC Web Reports• BTI Software (Medicare Eligibility Criteria and

professionally managing End of Life Care)– Health information support for Clinicians– Develop Reporting and quality assessment

functionality

Stage I: Internal Hospice of Stage I: Internal Hospice of the the Lakes FocusLakes Focus

Activated and Informed Patients and Families

• Focus group on comfort assessment and End of Life services

Prepared Practice Teams• Interdisciplinary group to review patient

flow into and through hospice as well as interdisciplinary functioning

Stage II: Organizational Stage II: Organizational FocusFocus

Educating Physicians in End of Life Care -- EPEC

• Gaps in EOL Care• Legal Issues• Elements – Models of

Care• Next Steps• Advance Care Planning• Communicating Bad

News• Whole Patient Assessment• Pain Management

• Physician-Assisted Suicide

• Depression, Anxiety, Delirium

• Sudden Illness• Medical Futility• Common Physical

Symptoms• Withholding/Withdrawing

treatment• Last Hours of Living

Patient and CaregiverPlan of Care

Comfort AssessmentMedicare Eligibility

Hospital

Nursing Home

Clinic

Home

Organizational Focus: Seamless Caring Across Venues

Stage II: Organizational Stage II: Organizational FocusFocus

Prepared Practice Teams• Develop End of life Care Plans that insure seamless transfers of

care across venues of care—admit from hospital• Educate and support prepared practice teams capable of smooth

handoffs– EPEC Training for

• GNPs• Hospitalists• ER Physicians• HPMG Physicians, Nurses and Social Workers

• Palliative Care Consultation Team Regions Hospital

Stage III: Member FocusStage III: Member Focus

Activated and Informed Patients, Members and Families

• Advanced care planning• Opportunities and challenges at the end of life• Addressing pain and suffering: Palliative Care

and chronic illness

    

   

   

PLAN

ACT

STUDY

DO

Act II: New modelAct II: New model

• Accountability and Patient Centered Changes– Admit patients within 24 hours– Admit from the hospital, avoid sending

patients home with complex medication management regimens

– No vending of patients– Focus on National productivity standards and

conditions of participation– Initiate new model of care: self-managed

teams

Self-managed Care TeamsSelf-managed Care Teams

• Definition: Self-managed teams are groups of interdependent individuals that can self-regulate their behavior on relatively whole tasks; responsibilities may include setting work schedules, developing performance, dealing directly with external customers, selecting own members and evaluating one another’s performance.

In Cohen et al. A predictive model of Self-Managing Work teams, “Human

Relations”, May 1996.

Predicted advantagesPredicted advantages

• Empowered employees

• Quicker decision-making

• Greater continuity: “We are your care team”

• Increased closeness to patients, caregivers, & care teammates

• Increased efficiency

• Increased flexibility

However, to implement…However, to implement…

• But: increased employee training is necessary so that staff know their jobs “inside and out” and can turn to each other as resources rather than supervisors.

• And: Supervisors must allow staff to “do their jobs” while maintaining responsibility for operational oversight and compliance (COPs) and care coordination.

ExpectationsExpectations

• Each team would be able to care for 25 to 28 patients

Evaluation, Outcomes and Evaluation, Outcomes and Problems 2003- 2005Problems 2003- 2005

• Increased census from 80 to 140 initially, then to 160; increased from 4 teams to 8 teams

• Developed an admission team• Lack of competent team supervisors• Poor understanding of the concept of self-

management teams• No clear role or authority for supervisors in the

model• Tremendous amount of ill will between staff and

management• Number of staff left the program or were let go

Load vs HOL horsepowerLoad vs HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2001 Year 2005

Advice to new leadership Advice to new leadership team?team?

Act III: Descriptive Sneaks Act III: Descriptive Sneaks inin

• 2006 to present– 2004 hired a new volunteer coordinator– Program director becomes ill in Mar 2005,

officially resigns in 2006– Hired new clinical supervisors – Division Director decides not to fill the

program director position, steps in as facilitator and invites me to be an active consultant-participant in the management team

Load versus HOL horsepowerLoad versus HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2006 Year 2008

Supervisory and Change Supervisory and Change StrategiesStrategies

• Engaging the actors not the critics (involvement and engagement)

– All Staff meetings became “campfire conversations seeking the wisdom of everyone to solve a problem or how best to change

– Get extensive input from affected staff prior to making a change

Early changesEarly changes

• March 2006: facilitated offsite by outside consultant for the new management team

• Create new leadership mission, vision and accountabilities for the leadership group

• All of the managers and supervisors became the leadership team: PALS– Focus on serving and supporting our staff so

that they can provide STEEEP care– Leadership and management commit to

working as a team

Developing a leadership and Developing a leadership and management teammanagement team

• Meeting Hygiene– Getting in “harness” weekly in a recognizable format– Tracking problems, interventions, outcomes– Facilitation and evaluate each meeting

• Management Rounds for supervisors– Everyone brings their tough cases and work together

on developing social practices that are recognizable and effective – (create a culture of decision-making principles, social practices on managing conflict)

– Create safe environment where supervisors can be direct with each other and recognize when they are being triangulated

Large Scale change neededLarge Scale change needed

• D x V x F > R

• March 2007 taking stock

– High dissatisfaction among old-timers

– Still significant underground of rumors, dissatisfaction and perception of the culture at HOL (intimidation, unfriendly, not enough preparation for new persons, etc)

Reinventing HOL Culture and Reinventing HOL Culture and ProgramProgram

• Decided to invite all interested staff in reassessing every aspect of our program from the first referral call through the bereavement process.

• Met for 4 half days approximately q two weeks on Fridays– Each meeting facilitated, design teams, small

group work, harvesting, post and vote– Some changes implemented immediately– Three follow-up work groups

Follow up groupsFollow up groups

• Culture change– Values– Healthy work place: respectful interactions– Training on managing conflict– Create an environment to support staff in their work

• Team Processes and work flow– Define roles, expectations, accountabilities and

characteristics of effective teams– Admission work group

• Rework computer screens and software• Develop smooth handoffs from the referral through

the handover to the assigned care team

Palliative and Hospice Care

Professional Caring and Healing Relationships

Practice management: info tools, workflow,

CMP

Hospice of the Lakes Program: The 3-legged stool

Respect for our people and

team

Health as the broad goal

The patient-centered experience

Good stewardship of

Successful care and caring for our patients and families rests on:

time, talent, & benefits

Continuum of Care: Processes and Analytic Tool

Referral Intake Staffing Admission Active Census Discharge

Palliative and Hospice CareMedicalPsychologicalSocialSpiritual

Professional Caring RelationshipsStaff InternalStaff ExternalPatient and Family

Practice ManagementInformationDocumentationWork Flow

Active Census = IDGs, Home-Hospital-NH Visits, Evening Night Call, Work Week and Week EndsPlatform of Care = Admission Team, Care Teams, Central Intake, Staffing, CTAs, Supervisors and Leadership

May 24May 24thth, 2007 Post and , 2007 Post and VoteVote

• Admission Team Processes

• Active Census Processes

– Team building

– Scheduling

– Computer Screens and software

• Leadership, vision for the future, developing a new compact, healthy workplace

Geographical ChangesGeographical Changes

• Catchment area approach defined by each team

– Reduced drive time

– Efficient use of each team

– Input from each team and whole program on drawing the catchment areas

Reinventing ourselves Reinventing ourselves • Develop systematic mentoring program for new hires (increased the

orientation from 1 month to the time it takes for the clinician to demonstrate competence and feel comfortable as a full fledged autonomous hospice clinician)

• Team processes– Professional role and accountabilities– Team accountabilities

• Effective Communication (voice mail nightmare)• Scheduling based upon need, synergism and effective use of each

team member• Developing, implementing and evaluating POC to meet the goals of

care of patient and family• Leadership accountabilities

– Outreach program– Involve and engage– Annual retreat

Care Team format changesCare Team format changes

• Changed format for weekly IDGs– Increase meeting time to 2 hours– Frequent check-ins and compassion fatigue

assessments– Take teams out to lunch– Intentional relationship building– Mutually create work formats within each

team, no cookie cutter approach • Hired .8 assistant volunteer coordinator and

assigned bereavement counselors to specific team

Hospice of the Lakes Hospice of the Lakes ValuesValues

What we stand by and strive for…What we stand by and strive for…

CARING

COMPETENCE

COMMUNITY

Ten thousand foot view of Ten thousand foot view of HOLHOL

Community

Competence

Caring

CaringCaring

We care for one another as we care for our patients, seeking to be trustworthy, respectful, understanding, compassionate, helpful, fair and thoughtful with one another.

CaringCaring

We hope to achieve this in all of our relationships.

• Patients and families• Staff to Staff• Management and Staff• HOL program staff and hospitals, clinics and nursing

home staff

CommunityCommunity

We are creating a work environment and working conditions that support the day to day work of all staff and the safe caring of our patients. We strive to communicate openly and directly with each other and our patients and families.

CommunityCommunity

Our work place will be characterized by• Continuing monitoring and adjustment of work

loads• Continuous quality improvement• Continuous improvement and ease of use of the

electronic medical record• Celebrations and recognition of the fine work

that we do• Regular renewal, retreats and skill building to

develop staff self-care and conflict management skills

CompetenceCompetence

We provide competent, state of the art palliative care to our patients and their families to alleviate suffering, and to maintain dignity and choice during one of life’s most difficult transitions.

CompetenceCompetence

We strive to be competent in all that we do.

We are mission and vision driven.

We facilitate solving problems.

We provide team based care with compassion, knowledge and respect to address physical, psychological, and spiritual suffering.

Some questions about next Some questions about next stepssteps

1. Do these values do justice to who we are and who we want to be? Is there anything we left out?

2. What images do you think would be helpful to capture who we are?

3. Please write down any advice you have to us regarding next steps.

Thank you for all your time and effort!

Report from the teamsReport from the teams

Strengths of the interdisciplinary teams• Clinically

– Focus teams away from traditional medical model of care with the RN at the center to a more equal/interdisciplinary approach to caring for the patient/family• creates a community of caring that

surrounds the patient and family• Plan of care is driven by patient and family

goals of care not medical model– Improved bereavement coverage of patients

StrengthsStrengths

• Operational efficiency, effectiveness and support– Increase support to one another– Coordination of visits based on needs of

patient (single plan of care understood by all)– Vacations: better coverage for pts and staff– Helps develop stronger interpersonal

relationships among staff– Shared responsibility for a caseload– Identified geographical territory: build

relationships with facility staff within territory

Strengths of ID Care Teams Strengths of ID Care Teams (cont)(cont)

• Increase field staff job satisfaction and more autonomy

• Improved communication among disciplines caring for family

• RNs follow more patients than in traditional case management (better utilization of RNs)

Weaknesses or areas of Weaknesses or areas of needed improvementneeded improvement

• Team scheduling takes considerable time unlike case management

• Each team member must know and perform their role: weak links increase the load for everyone else

• Difficulty in bringing in new RNs to the team • Intra-team conflicts create significant decrement

in team functioning and care of patients• More experienced hospice RNs have difficult

making transition from nurse case manager model to team model

• Not enough training in working as a team

• Staff turnover is difficult for the team

• More effective teams are rewarded with more work (have to mentor new RNs, take overload from other teams)

• Narrow /homogeneous patient population due to limited geography

Current CrisisCurrent Crisis

• “Load” is beyond capacity to provide care

– Team census increased from 25/30 to 35/40 in short period of time

– Vacations during the summer

– Several key RNs leave program

– Key social worker leaves program

Crisis ManagementCrisis Management

• Leadership group institutes daily huddles to solve problems, frequent communication

• Initiate frequent meetings with all affected staff (DxVxF>Stress &Leave)

• Determine what can be changed by Tuesday– D=unable to plan for week for the day because of

disruptions– Reduce unnecessary urgent admissions– Leadership grooms all admissions (changes work flow

of who decides something is urgent)– Hire temporary staff– Vend non HP patients– Recruit, recruit, recruit

Load versus HOL horsepowerLoad versus HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2001 Year 2005

Load versus HOL horsepowerLoad versus HOL horsepower

Hospice of the Lakes “horsepower” hauling the load

Increasing census

and requirements

Year 2006 Year 2008

Advice for next steps?Advice for next steps?