Slide 2 Kosnik 2003 1 2003 Illinois College of Emergency
Physicians On Our Watch Practical Tools for Collaboratively
Managing Hospital Demand Capacity January 10, 2003 Chicago Linda K.
Kosnik, RN, MSN, ANP, CEN Chief Nursing Officer,Overlook Hospital
Atlantic Health System Slide 3 Kosnik 2003 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. Slide 4
Kosnik 2003 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. Slide 5 In
Aviation SafetyThe 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. Slide 6 At the Atlantic
Health System we are exploring how Collaboration/CRM can be
operationalized with the outcomes of efficient Demand Capacity
Management CRMs 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 Slide 7 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. Slide 8 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
Slide 9 Kosnik 2003 8 A Microsystem Awakes We have used Gene
Nelsons 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
Medical Cost Patient Satisfaction Quality of Life Outcomes
Espinosa, 2002 Slide 10 Kosnik 2003 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) Slide 11 Kosnik 2003 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 Slide 12 Kosnik 2003 11
Field Notes : Stages In Our AHS Experience 1.Self Aware Microsystem
(m) 2.Like microsystems (m+m+m) 3.Unlike microsystems (m+m+m)
4.Microsystems to Macrosystems (m+ m +m +M) 5.Like Macrosystems
(M+M+M) 6.Macrosystems to Unlike Macrosystems (M+M+M) Kosnik and
Espinosa, 2002 Slide 13 Kosnik 2003 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 Slide 14 Kosnik
2003 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 Slide 15 Slide 16 Kosnik 2003 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 Slide 17
Kosnik 2003 16 Stage Two: Like Microsystems Collaborate IHI Waits
and Delays For the Emergency Department Collaboratives Emergency
Physicians Associates Collaboratives Patient Satisfaction Lab
Overlook ED ED Slide 18 Kosnik 2003 17 1998 and 1999 The IHI
Collaboratives n 1998 Collaborative 31Teams 31Teams Locations: AL,
CT, CA, FL, GA, IL, KY, MA, MD, NC, NJ, OH, TN, TX 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! Total Patients Per Year = 1,247,500 Results:
84% reached significant improvement over a 9 month period! n 1999
Collaborative 19 Teams 19 Teams Locations: Australia, CA, FL, IL,
MD, MO, NC, NY, OH, PA, TN, TX, UT, WV Locations: Australia, CA,
FL, IL, MD, MO, NC, NY, OH, PA, TN, TX, UT, WV Total Patients Per
Year =848,000 Total Patients Per Year =848,000 Results: 80% reached
significant improvement over a 9 month period Results: 80% reached
significant improvement over a 9 month period Slide 19 Kosnik 2003
18 ED Median Total Length of Stay Oak Ridge Methodist Medical
Center Week Slide 20 Kosnik 2003 19 Week ED Median Door to Doctor
Time Oak Ridge Methodist Medical Center Slide 21 Kosnik 2003 20 EPA
Collaborative Example Like Microsystem to Like Microsystem)
Collaboration (m+m+m) Example: Multi-hospital ED Multi-year Ongoing
Collaboratives: Slide 22 2000 to 2003 EPA/Team Health Collaborative
Select Topic Summarize Changes Identify/Select Participants Prework
Handbook Supports 1. Calls 2. Listserv / E-mail 3. Visits 4.
Monthly Reports (10th of each month starting in June 00) Learning
Session 1 LS2 LS3 5/00 9/00 5/01 Set Aims and Goals A P S D Key: P
= Plan D = Do S = Study A = Act A P S D Slide 23 Kosnik 2003 22
Average # Minutes To Transfer From ED Robert Wood Johnson
University Hospital Slide 24 Kosnik 2003 23 Average Time To
Transfer From ED to ICU/Telemetry - Massena Memorial Slide 25
Kosnik 2003 24 Median Times for All ED Patients Good Samaritan
Hospital Total Length of Stay Faster Care Slide 26 Lessons Learned:
Be Flexible Support 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. Slide 27
Kosnik 2003 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 Slide 28 Kosnik 2003 27 Stage three:
Unlike Microsystems Collaborate (m+m+m+m) Reducing Xray Turnaround
Times. Admission Cycle Time Safety Summit M ED Inpatient Units ICU
OR/RR Inpatient Units Envir Transport Lab Dietary Medical Staff
Pharmacy Case Management Radiology Management Slide 29 Example:
Reducing Admission cycle time ( m+m+m+m) Slide 30 Kosnik 2003 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. Slide 31 Kosnik 2003 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 satisfactionand reducing ED efficienciesbut 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 Slide 32
Kosnik 2003 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 Slide 33 Kosnik 2003 32
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 Admission Cycle Time Slide 34 Kosnik 2003 33
Benefits Reduce and/or eliminate holding Reduce and/or eliminate
divert Budget neutral solution Improved patient/staff/physician
satisfaction Benefits of Decreasing Admission Cycle Time Slide 35
Kosnik 2003 34 Admission Cycle Time Slide 36 Kosnik 2003 35 Average
Admission Cycle Time in Minutes Slide 37 Kosnik 2003 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) Slide 38
Kosnik 2003 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
Slide 39 Kosnik 2003 38 Example: Matching Capacity to Demand
Management To Drive Improvements In Flow (m+ m +m +M) Slide 40
Kosnik 2003 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 practicesacross
microsystem and macrosystems Decreased variation in practice
patterns Increased customer confidence Slide 41 Kosnik 2003 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 Slide 42 Kosnik
2003 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 Slide 43
Kosnik 2003 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 Slide 44
Kosnik 2003 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 Slide 45 Kosnik 2003 44 Green Slide
46 Kosnik 2003 45 Green What does a good day look like? Slide 47
Kosnik 2003 46 Green Interventions Slide 48 Kosnik 2003 47 Yellow
Slide 49 Kosnik 2003 48 Yellow Early triggers What can we identify
and manage early or on a regular basis? Slide 50 Kosnik 2003 49
Yellow Interventions Slide 51 Kosnik 2003 50 Orange Slide 52 Kosnik
2003 51 Orange Escalating demand without readily available capacity
Aggressive action required to avoid system gridlock Overload Slide
53 Kosnik 2003 52 Orange Interventions Slide 54 Kosnik 2003 53 RED
Slide 55 Kosnik 2003 54 RED Gridlock Disaster Plan response
required Slide 56 Kosnik 2003 55 RED Interventions Use
Institutional Disaster Plan Slide 57 Kosnik 2003 56 Slide 58 Kosnik
2003 57 AHS INPT FLOW 2001 Slide 59 Kosnik 2003 58 ICU Triage
Process Slide 60 Kosnik 2003 59 Forms, Grids and Flow Admission
Cycle Time Data Collection Form Admission Cycle Time Flow Chart ICU
Decision Flow Demand Capacity Grids Emergency Department Slide 61
Kosnik 2003 60 But Does It Really Work? Retention Rate= 90%
Admission Cycle Time A new collaborative approach to
Demand/Capacity decision making Time since last episode of Critical
Care Divert Full Divert Slide 62 Kosnik 2003 61 Days Since Last
Divert of Any Kind Slide 63 Kosnik 2003 62 Days Since Last Full
Divert Slide 64 Kosnik 2003 63 Stage Five: Like Macrosystems
(M+M+M) Demand Capacity Management Idealized Design for Falls
Management Service Lines M M M M Slide 65 Kosnik 2003 64 Example:
Matching Capacity to Demand Management Among Macrosystems (M+M+M)
Slide 66 Kosnik 2003 65 Advanced Spread of These Principles:
Creating more robust micro-systems/components/departments
Laboratory Radiology Respiratory Case Management/Social Work
Environmental Dietary Pharmacy Security Engineering
Purchasing/Materials Management Information Systems Volunteer
Services/ Transport Services Medical Records Patient
Representatives/ Pastoral Care MICU/EMS Radiation Therapy
Peri-operative services Post-Acute Slide 67 Kosnik 2003 66 Slide 68
Kosnik 2003 67 Slide 69 Kosnik 2003 68 Advanced interventions under
current design Advanced third-generation discharge program with
more idealized coordination with case management Advanced
system-wide on-call systems Advanced system-wide staffing system
Slide 70 Kosnik 2003 69 The Biology of Cooperation Some components
are better suited to support specific components, as well as the
macro-org (i.e. Environmental can provide support to dietary but
cannot provide support for transport) There appears to be a
hierarchy of impact (temporally) First service to be impacted is
tends to be transport (getting patients to services or services to
patients) The biology of multi-organ failure: The ability of
services to provide support significantly decreases with the number
of services in orange or red Slide 71 Kosnik 2003 70 Stage Six:
Unlike Macrosystems Collaborating Together (M+M+M) M R N Rehab Home
Care Nursing Homes Community EMS/Transport Slide 72 Kosnik 2003 71
Examples: Macrosystems Everywhere (M+M+M) Cardiac, Neuroscience,
Safety, Satisfaction Initiatives Disaster Plans Communication
between and to Nursing Home Reports Home Care Reports Doctors
offices Slide 73 Kosnik 2003 72 Keys to Success Building Trust Goal
is embedded predisposition to trust, Identify similar
characteristic and goals Experiences of reciprocity Achieved
through Microsystem management meeting Retreats Collaborative
Initiatives (MIC, Internal idealized design Summits Demand/capacity
collaborative Appreciative inquiry. Slide 74 Kosnik 2003 73 Keys to
Success Mitigate constraints/barriers within microsystem and
between microsystems Demand/capacity Management Operations Control
Center (OCS) Micro/macro work Internal collaboratives Idealized
designs Visual technology to reduce the Fog of War Biology of
cooperation Slide 75 Kosnik 2003 74 Keys to Success Facilitate
Reciprocal Relationships: Willingness and openness to reciprocal
action Storytelling Alignment of goals and strategies Appreciative
inquiry Flu season story as the precipitating incident ongoing
collaborative work in demand capacity throughout the system
Operations Control Center (OCS) Slide 76 Kosnik 2003 75 Keys to
Success Create a common language: Common vocabulary and syntax
Encourage interactions and conversations Work collaboratively to
solve problems Frame all activities as shared Create a common
language for shared information and resources across boundaries to
solve common problems OCS A common pain scale/degrees for the
economy for demand/capacity mismatch. Supply a framework for
collaborative sharing Linguafranca notion of a
microsystem/macrosystem social economy where people are
borrowing/sharing energy/money/social relationships.
Demand/Capacity load identification (example=color coding) Slide 77
Kosnik 2003 76 The United Nations of Micro/Macrosystems Use United
Nations thinking to Create a United Microsystems (UM) to solve
problems Demand/Capacity Issues Using this metaphor the UM members
need to trade with each other. Our experience defines stress states
using a color coding system. These are definitions that work for us
and may be similar to what you will define but it requires the
collaboration and participation of the UM I have created a grid or
process (a means for microsystems to come together and
collaborative) by which this can be achieved. To support
participation there may be a FTA (free trade agreement). If you do
not participate the system will levy a tax for not collaborating
and force those microsystems to find support from outside. Slide 78
Kosnik 2003 77 Future Steps Future steps---- Commonwealth
funds.virtual safety program which will teach people how to drive
the OCS Creating a symbolic language for the equations
M=macrosystem, m=microsystem, macro\macro collaboration Further
integration of CRM tools to promote collaboration Measurement of
the impact-flavor of the operational definitions. Promoting the
economic implications of the approach. Example= The cost of
inefficient demand capacity management. What are the rules that
apply. Slide 79 Questions.. Comments Considerations.