Amanda Stefancyk Oberlies, Pat Rutherford and Christine White
Hospital Flow Professional Development Program
November 2, 2016 Cambridge, MA
Redesign the System:
Improving Med/Surg
Efficiencies and Patient Flow
These presenters have
nothing to disclose.
Challenges on Medical and Surgical Units
Care teams in most medical and surgical units are facing increased demand due to shorter lengths-of-stay, aging of the population, increased complexity and acuity of patients, inefficient care processes and challenges in discharging patients with the “appropriate care” in a timely fashion. Delayed transfers of patients between nursing units and lack of available beds are significant problems that increase costs and decrease quality of care and satisfaction among patients and staff. The overwhelming majority of discharges occur on medical and surgical units, and discharge delays often create bottlenecks that negatively impact patient flow throughout the hospital.
Session Objectives
Describe innovative models for multidisciplinary
collaboration and rounding on medical and
surgical units
Identify approaches for creating clear, agreed-
upon care plans for each patient -- which are a
result of active participation of patients and their
family members, hospitalists, surgeons, nursing
staff and other care team members.
Cultivating Great Teams:
What Health Care Can Learn from Google
Psychological safety: Can team members take risks by sharing ideas and suggestions without feeling insecure or embarrassed? Do team members feel supported, or do they feel as if other team members try to undermine them deliberately?
Dependability: Can each team member count on the others to perform their job tasks effectively? When team members ask one another for something to be done, will it be? Can they depend on fellow teammates when they need help?
Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?
Meaning of work: Is the team working toward a goal that is personally important for each member? Does work give team members a sense of personal and professional fulfillment?
Impact of work: Does the team fundamentally believe that the work they’re doing matters? Do they feel their work matters for a higher-order goal?
NEJM Blog Post October 19, 2016 by Jessica Wisdom & Henry Wei
Institute of Medicine report
“The current system shows too little
cooperation and teamwork. Instead, each
discipline and type of organization tends to
defend its authority at the expense of the total
system’s function.” (2003)
Relationships shape the
communication through which
coordination occurs ...
Findings
Case Managers
NursesAttending Physicians
Physical Therapists
Nursing Assistants
Social Workers Technicians
Referring Physicians
Administrators
Patient care:A coordination challenge
Patients
For better...
Shared goals
Shared knowledge
Mutual respect
Frequent
Timely
Accurate
Problem-solving
communication
… or worse
Functional goals
Specialized
knowledge
Lack of respect
Infrequent
Delayed
Inaccurate
“Finger-pointing”communication
This process is called
“Communicating and relatingfor the purpose of task integration”
Efficiency & financial outcomes
Reduced turnaround time Increased employee productivity Reduced length of hospital stay Reduced total cost of hospital care Reduced inpatient hospitalizations Reduced total costs of chronic care Increased profit growth Improved operational excellence
Identify a work process that needs better coordination – maybe “treating our patients”
Which workgroups are involved?
Draw a circle for each workgroup and lines connecting between them • WEAK RC = RED
• MODERATE RC = BLUE
• STRONG RC = GREEN
• Color of the circle says how we are doing within each workgroup, color of the line says how we are doing between the workgroups
Relational mapping
RC = Shared Goals, Shared Knowledge, Mutual Respect, Supported by Frequent, Timely, Accurate, Problem-Solving Communication
Relational mapping of current state
WEAK RC
STRONG RC
MODERATE RCWorkgroup 1
Workgroup 2
Workgroup 3Workgroup 4
Workgroup 5
14
Example
RC matrix
Admin CC PCAs Phys PA&NP RNs ResTh
Administrative Support 1.79 1.79 1.79 1.79 1.79 1.79 1.79
Care Coordination 4.43 4.86 4.29 4.52 4.71 4.67 3.86
Personal Care Assistants (PCAs) 2.62 2.40 4.02 2.29 2.29 3.50 2.40
Physicians 3.58 4.26 3.47 4.25 4.19 3.84 3.50
Physicians' Assistants and Nurse
Practitioners (PAs & NPs) 3.75 4.29 3.39 4.30 4.55 3.96 3.20
Registered Nurses 3.37 4.08 3.70 3.55 3.98 4.22 3.49
Respiratory Therapy 2.57 2.57 2.57 3.14 3.14 3.43 4.00
Ratings of
R
a
t
i
n
g
s
b
y
© 2016 Relational Coordination Analytics, Inc. All Rights Reserved
Assessing current state
• Where is relational coordination currently working well? Where does it work poorly?
• How does this impact performance?
• What are the underlying causes?
• Where are our biggest opportunities for change?
© 2015 Relational Coordination Analytics, Inc. All Rights Reserved
Reporting backAssessing current state
• Which of our current structures support relational coordination?
• Which do not?
• Where are our biggest opportunities for change?
• Consider structures that can be developed locally (huddles)
• Also consider structures that require top leadership support (shared accountability, shared rewards)
© 2015 Relational Coordination Analytics, Inc. All Rights Reserved
Three kinds of interventions
Relational interventions to build the new relational dynamics
Work process interventions to connect new relational dynamics to improvements in the work
Structural interventions to support the new relational dynamics
Stanford University Press
Multidisciplinary Rounds at MGHAmanda Stefancyk Oberlies PhD, MBA, RN, CENPChief Executive OfficerOrganization of Nurse Leaders – MA, RI, NH, CT
Strategic Objectives at MGH
To develop improvements and innovations on nursing
care units that will:
• Improve the quality and safety of patient care
• Increase patient-centeredness
• Create more effective care teams
• Improve staff satisfaction and retention
• Improve efficiency
Leadership development of frontline staff and manager
Transformational leadership
Nurse autonomy and ownership of practice
Quality measures are tracked
Health care reform
23
The TCAB Process
Frontline teams generate new ideas: not the quality department, not administration
Testing ideas and measuring outcomes: Rapid-cycle testing facilitates change: “one nurse, one patient, one shift”
Implementing and spreading successful changes
Collaborative learning
Staff
generates
idea
Small tests
of changeSpread
TCAB at MGH
Why TCAB at MGH?
– Aligns with values and mission
– Aligns with focus on innovation
– Supports evidenced based practice
– Strategically positions MGH for the future
24
A New Role in Rounds
Green books served as catalyst
Restructured rounds in a way that created a more active
role for the nurse; formalized a role for the nurse
Changing the culture – this was difficult
One year later – more positive feedback
A New Role in Rounds
Collaboration and Satisfaction About
Care Decisions (CSACD)
Q #1 Over the past month, nurses and physicians planned together to make decisions about care for patients.
Q #2 Over the past month, open communication between physicians and nurses took place as the decisions about patients were made.
Q #3 Over the past month, decision-making responsibilities for patient care were sharedbetween nurses and physicians.
Q #4 Over the past month, physicians and nurses cooperated in making decisions regarding patient care.
Q #5 Over the past month, when making patient care decisions, both nursing and medical concerns about patients’ needs were considered.
Q #6 Over the past month, decision-making for patients was coordinated between physicians and nurses.
Q #7 How much collaboration between nurses and physicians occurred in making decisions for patients over the past month?
Q #8 How satisfied were you overall with the decisions made for patients over the past month – that is the decision-making process?
C. J. Baggs 1988
Collaboration and Satisfaction About
Care Decisions (CSACD)
Pre and Post Collaboration Results
1
2
3
4
5
6
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
Questions
Before
After
•Always
•Complete Collaboration
•Strongly Satisfied
•Never
•No Collaboration
•Strongly Dissatisfied
C. J. Baggs 1988
AJN TCAB Series (Sept 2008 - Aug 2009)
Redesign the system: A Comprehensive Approach to Caring for Hospitalized Medically Complex Patients
Christine White MD, MATAssociate Professor-Hospital MedicineCincinnati Children’s HospitalCincinnati, Ohio
James Anderson Center for Health Systems Excellence
This presenter has nothing
to disclose
November 2, 2016
Objectives
• Recognize the importance of inpatient care
coordination for hospitalized children with medical
complexity (CMC)
• Identify challenges and opportunities for the
development and implementation of inpatient CMC
services
• Identify strategies for achieving seamless
coordination across the care continuum for CMC.
• Recognize the value of integrating bedside providers
to improve the efficiency of inpatient rounds
Complex Care Patient
4 year old male with chromosomal disorder
• Severe neurologic impairment
• Hydrocephalus s/p Ventriculoperitoneal shunt
• Epilepsy (on multiple antiepileptic drugs)
• Gastrostomy tube dependent (s/p Nissen)
• Cleft lip and palate s/p repair with tracheostomy
dependence
• Chronic respiratory failure (BiPAP dependent)
• Hypothyroidism
• Spasticity
Complex Care Patient
Specialists Involved
• Complex Care Center
• Neurology
• GI
• ENT
• Pulmonary
• Physical Medicine & Rehab
• Plastic Surgery
• Endocrinology
Utilization
• 7 medical admissions in last year
• 50 inpatient days
• 5 ICU bed days
• Average of 3 consults/admit
• Average of 25 discharge medications
Definition: Children with Complex Medical Needs
• Children with complex medical needs rapidly growing population
• Group includes children with:
• A clearly identified medical specialty home
• Neurologic impairment
• Technology dependence
Definition: Children with Complex Medical Needs
Gastrostomy
tube
Tracheostomy
tube
Neurologic impairment
(ex: cerebral palsy,
brain injury)
At Risk Population
• High utilization of hospital resources
• Increasing admissions
• At risk for medication errors
• Limited longitudinal handoff between inpatient and outpatient
Challenges and Opportunities
38
Our
History/The
Problem
2011 2013
Complex patients distributed amongst all 5 HM teams
Creation of New Complex Care Team
Remainder of neurologically impaired and technology dependent patients distributed among other 4 HM teams
-Staffed by HM attendings (350 pts/year)
-Patients from CCC cohorted onto 1Hospital medicine (HM) team
-Staffed by CCC attending (105 patients/year)
-Other general HM patients also on team
Rationale for the Creation of an
Inpatient Medical Home
• Improve care coordination
• Provide more family centered care
• Improve the safety for these at risk patients
• Develop a core group of HM attendings
• Cohort patients onto one unit (if medically
safe)
Complex Care Team
• Created to provide specialized care to this unique
patient population
• All patients who are neurologically impaired or
technology dependent admitted onto 1 HM team,
including:
• Complex Care Clinic patients
• Palliative Care patients
• Transition Adult Care Patients
• Maximum 10 Patients
Multidisciplinary Rounds
Team Members
• Hospital Medicine Attending/Fellows
• Pediatric residents
• Medical students
• Advanced Practice Registered Nurses (APRNs)
• Bedside Nurses
• Pharmacist
• Dietician
• Unit Care managers
• Social Worker
• Patient’s Primary Physician/Consultant
• Chaplain resident
Care Coordination
Care Coordination Rounds
• A once/weekly meeting with unit care managers
• The team reviews each patient’s discharge goals,
outlining tasks to be completed prior to discharge
• Discharge goals are listed and updated in the electronic health
record
• A needs assessment tool serves as the framework for
the conversation
Needs Assessment Tool
• Equipment
• Home Health Care Needs
• Private Duty Nursing
• Transportation
• Medications
• Follow-up Appointments
• Social/Family Concerns
• Education Needs
Medication Reconciliation Rounds
• Medication reconciliation completed on admission,
transfer, and discharge
• The team pharmacist reviews each patient’s current
medications with the team before rounds weekly
• Medication Pathway: As patients progress toward
reaching discharge goals, the pharmacist proactively
reviews medications and mitigates anticipated barriers:
• Prior authorizations
• Need for refills
• Secondary insurance
Multidisciplinary Handoff
• On Friday afternoons, the outgoing and oncoming
attending physicians hand off patient care
• Team members from the outpatient complex care clinics
attend facilitating planning
for the hospital to home
transition
Outcomes
49
Physicians define
medical criteria in EHR on
admission
Patient meets
medically-ready criteria
Nurse places time stamp in
EHR
Goal to leave within 2 hours of
meeting all criteria
• Patient-focused around disease process improvement• Do not aim for an arbitrary time of day
Outcomes: Discharge Efficiency
Prior Work
50
Frontline Staff Engagement
Consult Timeliness
Pharmacy Process Change
How will this process apply to complex patients
with unique discharge needs?
SMART Aim
Increase the percentage of medically complex pediatric patients discharged within 2 hours* of
meeting medically ready criteria from 50% to 80% by September 1, 2014
*If criteria were met between 9:00pm – 7:00am, patients were not expected to leave until 9am
Key Drivers
Increase the percentage of
medically complex pediatric patients
discharged within 2 hours of meeting medically ready
criteria from 50% to 80% by
September 1, 2014
Anticipation of Discharge Care Needs
Staff Engagement in Discharge Preparedness
Care Coordination
Optimization of Team Structure
Discharge Goal Identification
54
Run Chart
Cohort
Patients on
Complex
Care Team
55
Run Chart
Cohort
Patients on
Complex
Care Team
Creation of
Complex Care
Admission
Order Set
56
Complex Care Order Set
© 2013 Epic Systems Corporation. Used with permission.
Group
Patients on
Complex
Care Team
Creation of
Complex
Care
Admission
Order Set
Weekly
Multidisciplinary
Care
Coordination
Rounds
Medication
Pathway
Needs
Assessment
Tool
Role
Assignments
Bi-Weekly Start Dates (Number of Patients)
Secondary Outcomes
Median LOS: 3.1 days to 2.2 days (p = .13)
Readmission rates: 31% to 22% (p = .23)
Stakeholder Feedback
P59
Family Feedback
• Very positive feedback from families:
– “I feel like things get done faster now”
– “Yellow team has been the best thing that happened to my daughter since we have been here”
– “You guys said you talked to my pediatricians in complex care clinic and the rehabilitation physicians but I didn’t believe it until I saw you in rounds together. This makes me feel great”
– “Is discharge always this easy?”
Attending /APRN Feedback
• In a focus group, attendings and APRNs felt:
• The dedicated team makes the care of complex
patients easier and more rewarding
• Structured meetings simplified and addressed the
complex needs of these high risk patients
• Communication and care coordination with the
families, outpatient primary care providers, and
subspecialists were strengths
61
Nurse Feedback
Item Strongly
disagree %
(n)
Disagree %
(n)
Undecided
% (n)
Agree
% (n)
Strongly
agree
% (n)
More resources than before
complex care team
0% (0) 0% (0) 43% (10) 48% (11) 9% (2)
More comfortable providing care
than before complex care
0% (0) 9% (2) 39% (9) 52% (12) 0% (0)
Complex care team members are
approachable and work well with
other disciplines
0% (0) 0% (0) 23% (5) 59% (13) 18% (4)
Have the appropriate amount of
staff/resources to care for complex
care patients
9% (2) 17% (4) 35% (8) 39% (9) 0% (0)
62
Resident Feedback
• Residents perceived the new team as “an efficient way to provide
care”
• “Working with the multidisciplinary team is the epitome of care
coordination.”
• “Managing complex patients with many problems as well as thinking
about all of the ancillary things they need going home is a good
exercise in the management of the overall patient, whereas in other
rotations, you are concentrated on one problem and once they are
recovered from their short term insult, go home without another
thought about their continued care after their hospital admission.”
63
Rounds Integration of
Bedside Providers: RN led
Rounds
Overall Aim
• Standardize chronic care processes and multidisciplinary
collaboration and communication
65
SMART Aim
• Increase the weekly percentage of RNs presenting
during daily pulmonary rounds in the tracheostomy unit
from 73% to 95% by July 1st, 2017
• Increase the weekly percentage of Respiratory therapists
presenting during daily pulmonary rounds in the
tracheostomy unit from 59% to 95% by July 1st, 2017
66
RN/Respiratory (RT) led rounds
RN Script 68
Tracheostomy Unit AM Rounding Sheet – Nursing
Pt Name: Date:
Significant Overnight Events/Concerns: (Desaturations, PRN medications, vent changes, storming, seizures, abnormal labs, symptoms of respiratory illness). Please include nursing recommendations if applicable.
Upcoming Tests/Procedures:
Consent Transport needed NPO Status Trach change Labs sent Pre-op Meds
Situational Awareness Specific to this Patient:
Critical Airway Subglottic Stenosis Grade___ Malacia Breath holding Seizure Rescue Storming Plan
Behavioral Plan
Other
Education Updates:
Barriers to Prevention Standards: (CABSI, CAUTI, VARI, Pressure Ulcer, Safe Care Bundle)
Medically Ready for Discharge: (Please circle one) Yes or No Needs to be completed: Barriers?:
Respiratory Therapy Script 69
Key Stakeholder Feedback
P70
% of Staff Members who Completed the Survey
Summary of change
Resources 73
• Cohen E, Kuo DZ, Agrawal R, et al. Children with
medical complexity: an emerging population for clinical
and research initiatives. Pediatrics. 2011;127(3):529-
538.
• Statile AM, Schondelmeyer AC, Thomson JE, et al.
Improving Discharge Efficiency in Medically Complex
Pediatric Patients. Pediatrics. 2016;138(2):e20153832.
Thank You to Our Team!
• Angela Statile MD, MEd
• Laura Brower MD
• Rebecca Brehob-Bucker,
RD
• Suzan DeCicca LSW
• Stacey Litman-Padnos,
LSW
• Julie Ostrye, PharmD
• Michelle Cobble, RN
• Abbie Ball, RN
• Rhonda Petsch, RN
P74
• HM attendings/fellows
• HM APRNs
• Pediatric residents and
chief residents
• Our outpatient partners
• Our unit nurses and RTs
• Dan Benscoter, MD
• Julie Clarke, RN
• Karen Tucker MSN, MBA,
RN
• Julia Edmonson
Questions or Comments?
Comparison of Quality of Communication Before and Current
I Feel Involved Comparison
Patient Status and Plan of Care Comparison
Capacity 79
80
Total Census = 2544
Total days = 365 Days %
Median Census 7.0
Days with census of 8 65 18%
Days with census of 9 44 12%
Days with census of 10 or more 39 11%
Yellow
PDSA # 1
PDSA # 2
PDSA # 3
PDSA # 4
