Modelling resilience in the Emergency Department: Escalation - - PowerPoint PPT Presentation

Modelling resilience in the Emergency Department: Escalation policies and patient flow Janet Anderson, Jonathan Back, Myanna Duncan, Peter Jaye & Alastair Ross

• Dr. Janet Anderson

Centre for Applied Resilience in Healthcare http://resiliencecentre.org.uk

Centre for Applied Resilience in Healthcare

• Collaboration between King’s College London,

University of Glasgow and Guy’s and St. Thomas’ NHS Foundation Trust

• Close clinical and governance links
• Quality improvement - drivers and approach
• Sites for in depth work –

– Emergency Department – Older Person’s Unit

Centre for Applied Resilience in Healthcare

ANALYSIS OF SECONDARY DATA, OUTCOME MEASURES, SYSTEM MODELLING OUTCOMES META NARRATIVE REVIEW OF RESILIENCE CONCEPTS AND TOOLS, DEVELOPMENT OF MEASURE OF RESILIENCE ETHNOGRAPHIC FIELDWORK Pressures that require organisational and team resilience How is safety created through resilient practices? How is safety threatened – drift, sacrificing j’ments, perceptions of risk SYNTHESIS OF RESULTS Synthesis, empirically validated theoretical model of resilience, recommendations for translating research into practice IMPLEMENTATION AND EVALUATION Data collection, observation, analysis of time series data, cost effectiveness

• WP8. EDUCATION AND DISSEMINATION

DESIGN EVALUATION TOOLS AND PROCESSES STUDY DESIGN AND SETUP OBSERVATION INTERVENTION DEVELOPMENT Collaborative work with clinical groups to develop tailored multi-level interventions IMPLEMENTATION AND EVALUATION

• 1. Develop, implement and

test organisational interventions to increase resilience, quality and safety

• 2. Shift focus of safety in the

NHS from analysing and counting incidents to

• rganizational resilience
• 3. Provide guidance and tools

to implement resilience based approaches

Organisational resilience

• Resilience is “the intrinsic ability of a system or an organisation

to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Hollnagel, 2011,

• p. xxxvi)
• Four cornerstones – anticipating, monitoring, responding and

learning

Success Failure

Eg harm, breaches of targets, standards, staff burnout, complaints, poor experience

Demand

Eg attendance, acuity, standards, targets

Capacity

Eg staff level, skills, equipment, procedures, escalation policy

Adaptations Adjustments Alignment

Work as Imagined Work as Done

Working Model

Fieldwork

• Focused study of escalation in action

– Document analysis – Non participant observations – n=27 hours – Semi structured interviews – n=6 – Thematic analysis – combined deductive/inductive approach

• Resilience narratives that describe how outcomes result from

the interplay of misalignments and adaptations

ED Patient Flow

Escalation in the ED

• Four hour target for admission to discharge for 95%
• Target breaches have financial consequences
• Escalation policy

– Mix of actions designed to improve flow – Internal and external escalation actions – Pre determined triggers for action – patient numbers at various points in the patient journey

• Metrics

– Occupancy, ambulance arrivals, acuity, average waiting times, wait for specialist input, bed status for hospital

Monitoring

• Patient flow co-ordinator

– Dedicated non clinical nurse role – Responsible for monitoring patient flow and initiating actions to avoid breaches

• Two hourly sitrep meeting
• Compiles patient numbers in each area
• Reconciles with IT system – lag
• Identifies bottlenecks and how to resolve
• Effect of escalation actions not monitored until

next sitrep meeting

Learning

• Performance metrics are disseminated each

day for the previous day

• Review of breaches focuses on classification

and justification not actions and their effects

• RCA performed if performance very bad
• Learning from success - successful avoidance
• f breaches is not discussed
• Effect of escalation actions not known

Misalignments

• Variable

– patient numbers – patient acuity – staffing and skill mix

• Capacity to treat and

discharge patients depends on availability

• f services

– Imaging, blood tests, beds, specialist services

Success Failure

e.g. harm, breaches of targets, complaints

Demand

e.g. patient numbers, targets

Capacity

e.g. staff level, staff skills, processes Adaptations Adjustments

Alignment

Work as Imagined Work as Done

Outcomes

• Differing definitions of

success

– Clinical outcomes – physicians – Patient flow – nurses

• Uneasy co-existence of

sometimes conflicting goals

• All breaches are seen as

equal - context of the demands not taken into account

Success Failure

e.g. harm, breaches of targets, complaints

Demand

e.g. patient numbers, targets

Capacity

e.g. staff level, staff skills, processes Adaptations Adjustments

Alignment

Work as Imagined Work as Done

Escalation Adjustments

• Invoking escalation creates extra

demands

– Planning and prioritising – Staff handover – Skills assessment and matching

• Escalation is avoided if possible

to deal with problems

Success Failure Demand Capacity Align

Work as Imagined Work as Done

Resilience narrative

The emergency department team considered triggering an internal escalation because patient occupancy numbers were approaching a predetermined trigger level (75 patients at 6PM). It was agreed that the situation should be monitored carefully, as patient waiting times to be treated were starting to increase. The Rapid Assessment Team doctor decided to work alongside the triage nurses, to expedite the treatment and discharge of low-acuity patients, so that the capacity to assess newly arrived patients could be increased. He had observed this need independently of the discussions of escalation in response to the top-level numbers in the whole unit. The overall trigger level does not in itself take into account imbalance (e.g. where levels in

• ne area may be problematic despite the threshold not being met); thus

this doctor took the decision to flex despite no formal escalation. Breaches were averted.

Resilience narrative

The department triggered an external escalation because of very high

• ccupancy levels and the realisation that the incoming night shift was short
• f nursing staff. This allowed for additional nursing staff from agency/bank

(temporary staffing) to be used at short notice. As the new staff arrived, this generated additional workload as handovers had to be performed while nurses were reallocated across the patient bays in the major injury unit. This process took around thirty minutes to

• complete. Meanwhile, there were patients waiting for intravenous
• infusions. It transpired that three of the additional nursing staff were not

able (lack of qualifications) or willing (lack of experience) to perform the

• infusions. The Nurse in Charge had to reallocate these nurses to other

areas, and seconded an experienced nurse from triage, assigning her to the task of performing infusions in the Majors area. Breaches not avoided.

Escalation Adjustments

• Under pressure normal functions are neglected
• Leads to increased need for adaptation

– Documentation not updated – Case reviews rushed – Patients unwell at discharge – Co-ordination failures

Resilience narrative

During a red internal escalation a porter arrived to transport a patient but the patient could not be transferred as notes were missing. Handover had been rushed and nurses were complaining about lack of

• information. One patient who was discharged was

refusing to leave because he said he was too unwell. A number of patients were forgotten because reminder stickers placed on the computer screen had been lost. Junior doctor presenting case to his consultant was challenged to justify his actions. The consultant was annoyed about the lack of relevant details being provided. Breaches not avoided.

Escalation Adjustments

• Unclear which metrics

are most important

• Timing of escalation is

important

• Previously successful

actions no longer work

• System becomes

uncontrollable and

• paque

Resilience perspective

• Adaptive capacity concentrated in one or two

dedicated roles

• Need to unpack the black box of patient flow

– Unclear which metrics are most important – Limited monitoring of actions taken to manage flow – Inadequate review of effective responses

• Implementation of escalation is subject to

adjustments and adaptations that are poorly understood but which are crucial to success and failure

Implications

• Opportunities for improvement

– Making the escalation process more transparent – understanding repertoire of adjustments and adaptations and under what circumstances they are successful – Improved monitoring of escalation actions – better targeting of actions taken during Sitrep meeting – Improved learning from what goes right – reports of previous day to include reflection on what worked and what didn’t

Dr Janet Anderson Janet.anderson@kcl.ac.uk Centre for Applied Resilience in Healthcare (CARe) http://resiliencecentre.org.uk/ Twitter: @CARe_KCL

• “Understanding resilience makes the difference between
• rganizations that inadvertently create complexity and miss

signals that risks are increasing, and those that can manage high-hazard processes well”. (Nemeth et al, 2008)

The safety cliff

• Let us imagine a group of people walking,

running and cycling along a cliff-top path, with a large drop to the ocean below.

• Our job is to move people along the path

continuously.

• But at the same time we want to stop

people falling off the cliff.

Monitoring as part of resilient process

• Here, we are up on the cliff top.
• We are shepherds.
• We are monitoring the process of cliff-top

walking

• The purpose of monitoring is to prevent

people falling off where we possibly can

Monitoring as

• utcome control
• Here, we sit on the beach below.
• Every time someone falls, we log this. Thunk!!
• We are monitoring cliff falls
• The purpose of monitoring is to react to falls and fix their

causes so they don’t happen again

Outcome monitoring: counting falls; retroactive investigation; intermittent negative feedback after failure. Process monitoring: close observation of performance including any drift towards the edge; prevention of falls where possible; constant feedback on behaviour Ross AJ, Anderson JE (2015) Mobilizing resilience by monitoring the right things for the right people at the right time In Wears RL, Hollnagel E, Braithwaite J (Eds.) The Resilience of Everyday Clinical Work Kent: Ashgate.

Anticipating

• How adequately does your organisation anticipate future

challenges?

– How often are future challenges assessed? – By whom? – Does the organisation have a clearly formulated ‘model of the future’? – Is the model explicit or implicit? Qualitative or quantitative? – How far ahead does the organisation plan?

Key questions

• What is resilience - how can we measure it?
• How can healthcare organisations be engineered

to be more resilient and how we would we know if they were?

• How is resilience related to other aspects of

quality and safety? – clinically effective, safe, patient centred,

efficient, timely, equitable

• What are the most important dimensions of a

resilient system? – anticipating, monitoring, responding, learning

Safety II – Resilient systems

• Proactive systems approach aimed at anticipating

and preventing problems

• Resilience – ability to adapt safely to pressures
• Key concepts

– Safety is not the absence of error – WAI is different to WAD – adaptation is constant – Outcomes emerge from the variability of everyday work – Learn from success and failure

How do we know we are safe?

• Safety is not the absence of error
• If we rely on error rates to indicate safety we

can only know how safe we were in the past

• We need to strengthen safety in the present

and future

Boundaries of safe

• peration

Miller & Xiao, 2007

Resilient attributes

Four attributes of resilient organisations -

• 1. Respond to regular and irregular conditions in an effective flexible

manner

• 2. Monitor short-term developments and threats and performance
• 3. Anticipate long-term threats and opportunities
• 4. Learn from past events, both positive and negative, and understand

correctly what happened and why

Responding to problems

• How would you know if your team is prepared and able to

respond to problems? Questions to consider -

– Do they know what to do? Are they capable of doing it? – Are there prepared responses for particular problems? Are these discussed and agreed upon? – Are these incorporated into training? How? – When, how often and by whom is it reviewed?

Monitoring

• How would you know whether your organisation/team is
• perating unsafely?

– What indicators are used? When? How? – How are these decided upon? – Are they reviewed and revised? – What are the delays between measurement and interpretation? – Are any process indicators used?

Role of senior leaders

• Detecting drift into unsafe zone
• Resolving tensions between productivity and safety
• Reducing complexity and procedure overload
• Supporting team capacity to respond, monitor, learn,

anticipate

Safe operating envelope

Current use of quality data

Learning

• How does your organisation/team learn?

– Is learning based on successes and failures? – Is learning continuous or only in response to events? – How does learning occur? – Who is learning – individuals, team? – How is learning shared?

Our scope

• Motivation – concern with improving quality and

safety and the limitations of many QI tools

• Focus on the organisation, teams, units
• We are not focused on individual level resilience
• We reject the idea that resilience is a way to get

more out of people or get them to do more in an under resourced service

Research programme

• Two initial clinical areas – elderly care,

accident and emergency

Elderly care Accident & Emergency

Patients have multiple chronic problems – often with sensory and cognitive deficits Acute patients treated in short time Patient numbers relatively stable High volume of patients Some ability to predict demands Low ability to predict demands Co-located MDT who co-ordinate care plans Large dispersed MDT Co-ordination required over time Short term co-ordination i d

Fieldwork questions

• Resilience in relation to what?

– What are the common misalignments?

• Defining success

– Inverse of failure?

• What constitutes adaptive behaviour?

– Work as done at the team, organisational levels

• Adaptations can be codified leading to the

need for further adaptations

– Adaptations that become formal policy