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

Leading Successful Change Urgency Coalition Vision Empowering Celebrate Consolidate

Transformation Process Idea Idea Consensus Consensus Implementation Implementation Generation Generation Building Building

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 Use these 5 Understand steps when developing a Collect data process improvement Analyze plan . Formulate

Analytical Approach to Process Improvement Observe Understand Interview Watch Collect data Respect Analyze Formulate

Analytical Approach to Process Improvement Observe Understand Gain understanding of Collect data the process and critical intervals . Analyze Formulate

Analytical Approach to Process Improvement Observe Understand Systematically obtain necessary Collect data macro and micro data. Analyze Formulate

Analytical Approach to Process Improvement Observe Understand Critical review the data Collect data to ensure accuracy. Analyze Formulate

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

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

Developing the Rationale Time in the Emergency Department What activities occur during this time Admit to Floor Door Time (arrival) interval? (departure)

Using Data Effectively by Identifying the Pathway

Developing the Rationale Time in the Emergency Department Registration Triage ED Room Provider Eval Diagnositics Admit to Floor Door Time (arrival) Lab Testing (departure) 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 4 th , 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 Inpatient Admission Discharges Process Discharge Physical Planning Plant

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

30 / 30 started in May 2016 Design the Project:

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 60% of patients Lab Testing receive lab tests

Impact Coefficient: Determine the % of patients that will be affected by a PI event 1 minute lab Decrease TAT for 60% of patients improvement = Lab Testing receive lab tests 0.6 min of overall TAT improvement

Impact Coefficient: Determine the % of patients that will be affected by a PI event 1 minute lab Decrease TAT for 60% of patients improvement = Lab Testing receive lab tests 0.6 min of overall TAT improvement Decrease TAT for 15% of patients CT Scan Reads receive CT scans

Impact Coefficient: Determine the % of patients that will be affected by a PI event 1 minute lab Decrease TAT for 60% of patients improvement = Lab Testing receive lab tests 0.6 min of overall TAT improvement 1 minute improvement = Decrease TAT for 15% of patients 0.15 min of CT Scan Reads receive CT scans overall TAT improvement

Current Utilization: 92% Current Utilization: 73% Staffing to Demand Sentara Northern Virginia

Diagnostic and CT Utilization compared with EDBA 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 22.7% 4.3% 16% Rate % High 71.2% 47.3% 64% Acuity

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 0 4:00 Assist with constraints and de-escalation 1 0:04 Set up for warming or cooling hypothermic or 0 0:06 Provide post mortem care 0 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