High Performance Management: What Change Can Look Like N. Adam - - PowerPoint PPT Presentation

High Performance Management: What Change Can Look Like

• N. Adam Brown, MD, MBA, FACEP

System Chief - Sentara Northern Virginia Medical Center Regional Medical Director – Envision, Mid-Atlantic Region May 3rd, 2017

Sometimes the ED feels this way…

https://www.youtube.com/watch?v=8NPzLBSBzPI&feature=em- share_video_user

Agenda

Be an effective leader Be an effective leader Analyze data strategically Analyze data strategically Create winning plan Create winning plan Review a case study Review a case study

Management versus Leadership

Management Coping with complexity Planning and budgeting Organizing and staffing Controlling Problem-solving Leadership Creating and managing change Setting a direction Aligning people Motivating Inspiring

Leading Successful Change

Urgency Coalition Vision Empowering Celebrate Consolidate

Idea Generation Idea Generation Consensus Building Consensus Building Implementation Implementation

Transformation Process

Hierarchy of Needs

Hierarchy of Needs

Hierarchy of Needs

Hierarchy of Needs

Hierarchy of Needs

Types of Process Improvement Methods

Total Quality Management Six Sigma LEAN Re-Engineering Just-In-Time

Shift from Macro to Micro Data to Analyze Data Effectively

Macro Data Monthly Aggregate Reports Ex: Median Overall Treat and Release Time Micro Data Interval Median Times Ex: Median Door to Triage Time

Examples of “Macro Data”

Monthly Left-Without-Being-Seen Overall Door to Decision Times Overall Door to Doctor Times Average Door to Discharge

Examples of “Micro Data”

Lab Order to Collect Time Lab Collect to Lab Receive Lab Receive to Lab Report X-ray Performed to Read Time Transport Time to Radiology Door to Triage Time Physician Admit Order to Bed Assignment

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate

Use these 5 steps when developing a process improvement plan.

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate

Interview Watch Respect

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate

Gain understanding of the process and critical intervals.

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate

Systematically

• btain necessary

macro and micro data.

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate Critical review the data to ensure accuracy.

Analytical Approach to Process Improvement

Observe Understand Collect data Analyze Formulate Pair the data, analytics and process to formulate a cohesive plan of action.

Developing the Rationale

Time in the Emergency Department Door Time (arrival) Admit to Floor (departure)

Developing the Rationale

Time in the Emergency Department Door Time (arrival) Admit to Floor (departure) What activities

• ccur during

this time interval?

Using Data Effectively by Identifying the Pathway

Developing the Rationale

Time in the Emergency Department Door Time (arrival) Admit to Floor (departure) Registration Triage ED Room Provider Eval Diagnositics Lab Testing Dispo Decision Departure

Developing the Rationale: Dividing the Times

Daily Activities

Daily metrics reports Email and in-person dialogue Visual management boards Address immediate concerns/issues Celebrate successes Identify opportunities for improvement

Interval Activities: Weekly and biweekly team meetings

A Case Study: Sentara Northern Virginia System-wide focus on Treat-and-Admit Times

Location: Woodbridge, VA Community Hospital 184 Licensed Beds 42 Bed ED 45,000 Annual ED Volume

Downstream log jam worsened our turnaround times and patient quality.

Median turnaround times were between 550-600 minutes (9- 10hrs) for admitted patients. 2016 Goal: 317 minutes

Patient boarding is our number one challenge.

A patient who remains in the emergency department after the patient has been admitted to the facility

An Average January Day at SNVMC: 135 hours of Boarding Daily

January 4th, 2015 9pm SNVMC 23 admitted patients with no beds assigned.

Boarding compromises patient care.

Boarding results in:

• Prolonged patient waiting times
• Increased suffering for those who wait
• Compromises quality of care and patient safety
• Lying on gurneys in hallways for hours, and even

days

• Negatively affects staff morale
• Compromises ability for ED to respond to disasters
• Negatively affects the patient experience

Boarding causes are multifactorial.

Nursing Shortages Admission Process Physical Plant Discharge Planning Inpatient Discharges

Steps to a solution: Create urgency.

Gain momentum and support by creating urgency.

• Medical Affairs Committee Presentation
• Biweekly C-Suite Meetings
• Daily/weekly discussions with nursing leaders

Steps to a Solution: Build the Team.

Build a coalition / action team Identify the key stakeholders Keep the team small Choose wisely Be strategic

Steps to a Solution: Build the Team.

Build a coalition / action team Identify the key stakeholders Keep the team small Choose wisely Be strategic

Institutional culture contributed to our problem.

Identify the Reasons for Lengthy Decision to Admit Times #1 ED was not the focus.

• No institutional push/pull
• RN Supervisor “held” inpatient

beds for the following:

• Staffing
• Perceived or potential

acuity

• EVS
• Supported by Admin

Overarching Tactics

Senior administration involvement Weekly throughput meetings Consistent agenda Data and process focus (keep personalities out) Determine impact coefficient Identified barriers Petitioned administration for resources Track results

Design the Project: 30 / 30 started in May 2016

Opportunities for T/A Improvement

Bed availability Decreasing Report and Transport Times Utilization of surge beds

Tracking Barriers to Bed Placement

Mattresses

Tracking Barriers to Bed Placement

Nurses

Using Data Effectively by Identifying the Pathway

Opportunities for T/A Improvement

Attending call back times Standardized admission protocols Diagnostic and lab TAT Staffing: Provider, RN, Tech Impact Coefficient

Performance Metrics

Impact Coefficient: Determine the % of patients that will be affected by a PI event

Decrease TAT for Lab Testing 60% of patients receive lab tests

Impact Coefficient: Determine the % of patients that will be affected by a PI event

Decrease TAT for Lab Testing 60% of patients receive lab tests 1 minute lab improvement = 0.6 min of overall TAT improvement

Impact Coefficient: Determine the % of patients that will be affected by a PI event

Decrease TAT for Lab Testing 60% of patients receive lab tests 1 minute lab improvement = 0.6 min of overall TAT improvement Decrease TAT for CT Scan Reads 15% of patients receive CT scans

Impact Coefficient: Determine the % of patients that will be affected by a PI event

Decrease TAT for Lab Testing 60% of patients receive lab tests 1 minute lab improvement = 0.6 min of overall TAT improvement Decrease TAT for CT Scan Reads 15% of patients receive CT scans 1 minute improvement = 0.15 min of

• verall TAT

improvement

Staffing to Demand

Current Utilization: 92% Current Utilization: 73%

Sentara Northern Virginia

SNV SLR Total EDBA CT 21% (850) 13.7% (373) 18.5% (1223) 16% X-ray 44% (1749) 38.5% (1047) 42.2% (2796) 44% MRI 0.2% (8) .003% (1) .14% (9) 1% U/S 10% (391) 6.2% (169) 8.4% (560) 5.7%

Admit Rate

22.7% 4.3% 16%

% High Acuity

71.2% 47.3% 64%

Diagnostic and CT Utilization compared with EDBA

Over 30 patients in the ED correlates with TAT

Average

ED Tech Activity Freq Best

iStat - Collect laboratory specimens: collecting

16 0:05

Collect ED laboratory specimens: collecting

17 0:05

Assist with diagnostics blood culture procedures

2 0:07

Assist with physical examinations

7 0:05

Assistance with patient safety, mobility and body

15 0:03

Wound care and splinting: cleaning, prepping

7 0:10

EKGs and heart rhythm monitoring

15 0:05

Vital signs: e.g., blood pressure, temperature

23 0:03

Sit with patients 1:1

4:00

Assist with constraints and de-escalation

1 0:04

Set up for warming or cooling hypothermic or

0:06

Provide post mortem care

0:08

Insert straight Cath (no Foley)

1 0:07

Providing instruments to MDs and RNs as they

1 0:10

Assist MDs, RNs, Ancillaries with Patient Throughput Assist with patient triage

15 0:05

Transfer patients to inpatient units, to and front

10 0:07

Room cleaning and turnover

14 0:04

Remove IVs and final vital signs before

9 0:03

Deferrable work: stocking (refilling) carts

6 0:07

ED Tech Staffing Implications

The capacity analysis for June ED Techs requires a 1.5 FTE increase and a shift in staffing escalation from 3pm to 1pm daily

1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ED Tech FTEs Hour of Day

June ED Tech Staffing Analysis

Reqd Techs June Techs Opt Staff Current Staff

• June workloads require 1 additional ED

Tech

• Actual June Staffing was ~1.5 FTE low
• Daily workloads require 6 ED Techs

from 2-9p

• The June workload increased at 1pm

daily, requiring a 2 hour earlier shift start

Significant gaps in technician staffing exist during our busiest times.

1 2 3 4 5 6 7 8 9 10 6/2 0 6/2 6 6/2 12 6/2 18 6/3 0 6/3 6 6/3 12 6/3 18 6/4 0 6/4 6 6/4 12 6/4 18 6/5 0 6/5 6 6/5 12 6/5 18 6/6 0 6/6 6 6/6 12 6/6 18 6/7 0 6/7 6 6/7 12 6/7 18 6/8 0 6/8 6 6/8 12 6/8 18 6/9 0 6/9 6 6/9 12 6/9 18 6/10 0 6/10 6 6/10 12 6/10 18 6/11 0 6/11 6 6/11 12 6/11 18 6/12 0 6/12 6 6/12 12 6/12 18 6/13 0 6/13 6 6/13 12 6/13 18 6/14 0 6/14 6 6/14 12 6/14 18 6/15 0 6/15 6 6/15 12 6/15 18 ED Tech FTEs Date ‐ Time

June ED Tech Workload vs Actual Staffing

(6/2‐6/15)

Tech FTEs ESI Calc Workload

ED Tech Workload Estimation

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 6/2 0 6/2 6 6/2 12 6/2 18 6/3 0 6/3 6 6/3 12 6/3 18 6/4 0 6/4 6 6/4 12 6/4 18 6/5 0 6/5 6 6/5 12 6/5 18 6/6 0 6/6 6 6/6 12 6/6 18 6/7 0 6/7 6 6/7 12 6/7 18 6/8 0 6/8 6 6/8 12 6/8 18 6/9 0 6/9 6 6/9 12 6/9 18 6/10 0 6/10 6 6/10 12 6/10 18 6/11 0 6/11 6 6/11 12 6/11 18 6/12 0 6/12 6 6/12 12 6/12 18 6/13 0 6/13 6 6/13 12 6/13 18 6/14 0 6/14 6 6/14 12 6/14 18 6/15 0 6/15 6 6/15 12 6/15 18 ED Tech FTEs Date ‐ Time

June ED Tech ESI‐based vs Census‐based Workload Estimates

(6/2‐6/15, excluding 1‐on‐1 stitting)

ESI Calc Workload Census‐based Workload Calc

Potential Drivers for Simplification

• ESI mix is fairly consistent throughout the day
• Tech hourly workload by ESI level is similar
• Admissions are spread evenly across ESI level, at ~18%

Significantly Increased Technicians Significantly Increased Technicians Right-sized Provider and RN staffing Right-sized Provider and RN staffing Hired Transporters Hired Transporters Increased Radiology Providers in Overnights Increased Radiology Providers in Overnights Created capacity alerts to trigger on-call staff Created capacity alerts to trigger on-call staff Improved urinalysis equipment Improved urinalysis equipment Reduced RN to Floor Report Times Reduced RN to Floor Report Times Expanded Surge Units and D/C Lounges Expanded Surge Units and D/C Lounges

Conclusions

By December 2016, our median TAT for Treat and Admit was…

Project Conclusions

By December 2016, our median TAT for Treat and Admit was…

270 minutes

250 minute reduction in 9 months

Lessons Learned

“Chief” must lead the process and be seen to lead the process Management is more important than process. Unit leaders and stakeholders must lead from the front. Face-to-Face Communication not emails Watch for backsliding

Key Takeaways

Leadership takes strategy, vision and team empowerment Identify named and unnamed leaders Beware of macro data Have a data strategy Keep improving!