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 - PowerPoint PPT Presentation

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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

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Title: 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


1
Implementing Process Redesign Strategies for
Improving Hospital CareShinyi Wu,
PhDAssistant Professor, Epstein Department of
Industrial and Systems Engineering University of
Southern California and RAND
  • September 15, 2009, presented at AHRQ Conference

2
AcknowledgementCo-authors, Sponsor, and
Participants
  • Marjorie Pearson, PhD, _at_ RAND
  • Lisa Smith, RN, BSN, BS, _at_ UHC
  • Raj Behal, MD, MPH, _at_ Rush University Medical
    Center
  • Julie Cerese, RN, MSN, _at_ UHC
  • Helga Brake, PharmD, CPHQ, _at_ Northwestern
    Hospital
  • Joanne Cuny, RN, BSN, MBA, _at_ UHC
  • Ryan Mutter, PhD, _at_ AHRQ
  • Michael Harrison, PhD, _at_ AHRQ
  • The participating healthcare organizations

3
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
    _at_ Night project
  • Identified third shift had a significantly lower
    survival rate, mismatch between patterns in
    admissions / discharges, and about 50 paging
    non-urgent

4
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. DemandSupply

5
24/7 Redesign Strategies
  • Four demand and a customized supply best
    practices
  • Developed from the NHS model, literature review,
    and advisory group recommendations

6
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

7
Commit to ACTion Implementation Process















Step 1



Improvement Design Identify Team Complete
Project Charter Conduct Gap Analysis Select Best
Practices to Implement



Step 2


Plan Implementation of InterventionsCreate an
Implementation Plan for each intervention
























Performance Improvement Model





Step 3







Implement Interventions Execute activities and
implement best practices



























Step 4






Measure Results, Analyze Data, and Act on Results




Step 5













Standardize Communicate










8
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
  • Demandsupply 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

9
Results CTA Participation Was High But Took
Longer
CTA collaborative call participation average
90, range 70 to 100
Activities Planned wks Actual wks (supply wks)
Preparation 4
Design Improvement 3 7
Plan Implementation 2 6
Implement 24/7 strategies 4 5
Measure and analyze 3 10
Act on results 2 4
Measure, analyze, standardize communicate 10 45 (38)
Total 24 81
10
Implementation Results
24/7 Strategy Level 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 Policy 9 (16.2) 28 (29.5)
The comparison sites have high penetration of the
same strategies.
11
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

12
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

13
More Lessons Learned
  • 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

14
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?
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