Implementing Process Redesign Strategies for Improving Hospital Care

Shinyi Wu, PhD

Assistant Professor, Epstein Department of Industrial and Systems Engineering University of Southern California and RAND

September 15, 2009, presented at AHRQ Conference

Acknowledgement:Co-authors, Sponsor, and Participants

Marjorie Pearson, PhD, @ RAND Lisa Smith, RN, BSN, BS, @ UHC Raj Behal, MD, MPH, @ Rush University Medical Center Julie Cerese, RN, MSN, @ UHC Helga Brake, PharmD, CPHQ, @ Northwestern Hospital Joanne Cuny, RN, BSN, MBA, @ UHC Ryan Mutter, PhD, @ AHRQ Michael Harrison, PhD, @ AHRQ The participating healthcare organizations

Why Redesigning Hospital Care? Literature:

Hospital care at night is not as safe or patient-centered as care provided during weekdays

National Health Service (UK) Hospital at Night Model: Found mismatch between activity at night and

staffing structure (e.g., experience, competencies) UHC “Improving Survival” project and pilot

“Care @ Night” project Identified third shift had a significantly lower

survival rate, mismatch between patterns in admissions / discharges, and about 50% paging non-urgent

Test A Structured Process Redesign Intervention to Help Hospitals Improve Efficiency and Value Design, deliver, and evaluate an intervention

“24/7 Care Delivery Model” Aimed to redesign care delivery in hospitals for

efficiency and consistency around the clock Intervention components:

Redesign strategies: modifying workload demand vs. adjusting staffing model

A structured approach to facilitate improvement Compare overall and relative importance of

redesign strategies Demand vs. Demand+Supply

24/7 Redesign Strategies: Four “demand” and a customized “supply” best

practices Developed from the NHS model, literature review,

and advisory group recommendations

Customized staffing supply

Discharge planning

Structured Handoffs

Paging Policy

Common Complains

PRNMedications

UHC Commit to ACTion Facilitation Approach A set of implementation tools including best practices Organizational commitment from each participating

organization Designated improvement team & a team leader with

time commitment Identified executive sponsor, a nurse champion, and

a physician champion to provide support and resources

Collaborative learning facilitated via teleconference and emails Separate facilitation by intervention arms

Operated as a member service, on voluntary basis

Step 1:

Implement InterventionsExecute activities and implement best practices

Step 2:Plan Implementation of InterventionsCreate an Implementation Plan for each intervention

Step 3:

Step 4:Measure Results, Analyze Data, and Act on Results

Improvement?Yes: Step 5No: Step 2

Performance Improvement

Model

Step 5:Standardize & Communicate

Improvement DesignIdentify Team Complete Project CharterConduct Gap AnalysisSelect Best Practices to Implement

Commit to Commit to ACTACTion Implementation ion Implementation ProcessProcess

Evaluation Methods Quasi-experimental design with three arms

15 academic medical centers across the US Demand intervention: 4 hospitals, including 4 meds & 2

surgical services, 10 nursing units Demand+supply intervention: 6 hospitals, including 4

meds & 3 surgical services, 13 nursing units External comparison: 5 hospitals, including4 meds & 4

surgical services, 12 nursing units Implementation assessment

Triangulation and coding of data from CTA observations, document review, CTA data analyses, and two rounds of interviews

Impact assessment Participants perceived impact and lessons learned Diff-in-Diff analyses of efficiency and quality measures

Results: CTA Participation Was High But Took Longer

ActivitiesActivities Planned wks Actual wks (supply wks)

Preparation 4Design Improvement 3 7Plan Implementation 2 6Implement 24/7 strategies 4 5Measure and analyze 3 10Act on results 2 4Measure, analyze, standardize & communicate

10 45 (38)

Total 24 81

CTA collaborative call participation: average 90%, range 70% to 100%

Implementation Results

24/7 StrategyLevel of 24/7 strategies at

baseline in % (SD)

% (SD) of 24/7 strategies

implemented

Structured handoffs

57%(22.3%)

43%(26.3%)

Discharge planning

32%(14.1%)

41%(37.5%)

Common complaints

Medications

45%(39.9%)

37%(43.2%)

Paging Policy9%

(16.2%)28%

(29.5%)

The comparison sites have high penetration of the same strategies.

Perceived Major Gains

Opportunities to communicate with and learn from other hospitals

Data to understand current practice and staffing gaps

Multidisciplinary perspectives and discussions Demand strategies improved care routines,

coordination, workflow, and decreased interruption

Supply strategies helped better distribute nighttime and weekend workload

Lessons Learned

Lack of geographical localization is the biggest barrier for 24/7 care redesign

Physicians’ and leaders’ buy-in and push for changes are important Especially for complex care processes & clinical

authorization Key facilitators to changes

Senior leader support Team leader facilitating implementation and successfully

communicating to staff Clearly presented data reports can be powerful

tools Even for making major changes in staffing arrangements

24/7 activities set the stage for continual and subsequent change efforts

Long-term, multi-factorial, pilot unit-based intervention is difficult

Recommendations from participants for others: Engage frontline staff and direct care providers Involve people with operation authority on the units Orient team members and staff Maintain constant communication with everyone Recognize that active support from leadership may

be needed

More Lessons Learned

Conclusions & Implications Hospital participation in CTA was high

The process was longer than anticipated Resulted in some changes in care delivery systems and

processes at all hospitals Most clinical outcomes changed as expected, but not

efficiency measures Each of the 24/7 redesign strategies was implemented in

some hospitals and had different effects on outcomes Demand strategies improved efficiency and consistency

of care processes Supply strategies might be needed to improve care

around the clock Can 24/7 strategies be implemented without CTA

facilitation?