Transformational Leadership Experience From Inception to Implementation National Healthcare Leadership Conference June 11, 2007 Dr. Keith Rose Vice President and Chief Medical Executive North York General Hospital
Agenda � Anesthesia Care Teams � Coaching Teams � Wait Time Incremental Cases � Innovative Delivery Models � Cataract High Volume Centre � Total Joint Assessment Centre � Summary – Keys to Success
Anesthesia Care Teams (ACT)– Why? � Health Human Resource supply issue: Anesthesiologist shortages across Ontario and Canada � The shortage of Anesthesiologists in the health care system has been a contributing factor in the following results in Ontario: Growing surgical wait times � � Cancelled surgeries Operating Room closures �
Anesthesia Care Teams – Alternate Care Providers � Anesthesia Assistant � Registered Nurse or Registered Respiratory Therapist can, with additional training, expand services provided by Anesthesiologists � Participates in the care of stable surgical patients during local, regional, or general anaesthesia under medical directives and under the supervision and immediate availability of the Anesthesiologist. � Anesthesia Nurse Practitioner � Nurse/RT Monitor
Anesthesia Care Team Model Example � Use of anesthesiology teams for cataract surgeries � One anesthesiologist covers two rooms Provides clinical support to Nurse/RT Monitor or Anesthesia � Assistants who establish IVs, administer sedation, and patient monitoring Increase cataract surgical volumes � � Maintaining patient safety
ACT Demonstration Site Project In August 2006, Associate Deputy Minister Hugh MacLeod � invited interested Ontario hospitals to submit an Expression of Interest to develop an Anesthesia Care Team Demonstration Site The ministry was interested in evaluating different � models of anesthesia care in pre-operative, intra-operative and post-operative settings. The government also wanted to assess the effectiveness of the ACT in Community and Academic hospitals
ACT Demonstration Site Project cont’d � Demonstration sites are expected to run for 2 years and will roll out in 2 to 3 phases depending on the level of interest and availability of trained personnel: Phase I launched in 2006 � � Phase II starting in late 2007
Expressions of Interest � 42 Ontario hospitals submitted Expressions of Interest to develop an ACT Demonstration Site. These submissions covered pre-operative, intra- operative and post-operative settings: � 31 pre-operative proposals � 42 intra-operative proposals 29 post-operative proposals � � Proposals came from Community Hospitals and AHSCs across Ontario. Hospitals in all 14 LHINs submitted Expressions of Interest.
ACT Proposal Review Process � Detailed criteria were used to review the proposals (in order of importance): Merits of Proposal � � Anesthesia Shortfall � Readiness to Proceed � Wait List Cases � Budget
Funded Demonstration Sites 16 Projects � � 2 pre-operative � 10 intra-operative � 1 post-operative � 3 other 10 Hospitals � � 4 community hospitals � 6 teaching hospitals � 7 LHINs 44 Staff � � 38 anesthesia assistants � 6 registered nurses
Evaluating Demonstration Sites � Objective: � Identify safety and efficiency of ACT model for pre-operative assessment, intra-operative care and acute pain services � Indicators: � Patient safety � Clinical efficiencies � Patient & staff satisfactions � Methodology: � Compare prospective & retrospective data from Demonstration sites � Compare patients treated by ACTs to patient treated without an ACT � Data collection � Web-based database registry
Anesthesia Care Teams Challenges � Change management process � New roles and relationships � Training program � RT/RN choice � Funding for physicians � Time and effort for implementation was underestimated
Coaching Teams – Operating Rooms What are coaching teams? � Coaching teams are peers with experience in effective management of peri-operative resources, trained as coaches � They assist hospitals assess their peri-operative processes � Based on expert panel recommendations � First visits began in January 2006 � First return visits began in November 2006
Coaching Teams Team Composition Team composition depends on the issues identified by the � hospital through their Expression of Interest. Teams generally include four members from the following areas: One Physician � One or two Senior Administrators � One or two OR Leaders � Out of the 32 coaches; 8 are Physicians, 13 are Administrators and 11 are OR Leaders � Affiliation ranges from teaching hospitals, community hospitals and � small/rural hospitals.
Coaching Teams - Themes � Leadership and Accountability � Allocation of OR Resources � Flow and Space Issues � Data Collection � Human Resource Issues � Equipment and Supplies
Coaching Teams – Follow-up Coaching follow up visit Occurs between 6 and 9 months � 2-3 hour on site visit � � Senior management representation � Perioperative team members Coaching team members (physician and administrative lead) � Follow up with the team to evaluate successes/challenges � � Review and assessment of progress with action plan More advisory in nature �
Coaching Teams – Early Observations Broad engagement of perioperative team and senior management � Consensus of issues � Readiness for change � Coaching process has assisted with team development � Helps provide direction for the team � Improved access to expertise �
Coaching Teams –Early Observations Coaching for action/trusted advisor was the right model � Coached organizations are leveraging the model internally � � Using the coaching process for other departments Organizations are finding capacity, savings and improving quality � Coaching teams have identified system problems which are being addressed � � Process mapping workshops being developed for hospitals
Coaching Teams - Challenges � Some organizations see coaching teams as an evaluation rather than an opportunity for learning and growth � Some organizations have been slow to adopt � Implementation of recommendations
Coaching Teams – Future Steps Evaluation of the coaching process by University of Toronto � researchers; initial work started in January 2007 Development of follow-up visit assessment tools, development � of data trend analysis and tools that measure change and improvement Updated website – materials for coaches and hospitals � Toolkit of useful tools and templates created and accessible to � all hospitals
Wait Time Incremental Cases � Additional funding has been provided to perform incremental volumes in the following areas: � MRI Cardiac � � Cancer surgeries � Joints (Hips and Knees) Cataract surgeries � � Paediatric surgeries � Endoscopy � Chemotherapy visits
Wait Time Incremental Cases Accomplishments Decrease in wait times � Increased efficiency � � Surgical Efficiency Target (SET) � Process Mapping Standardization � Focus on Quality �
Wait Time Incremental Cases Accomplishments continued � New IT Infrastructure � Wait time management � Scheduling process � Acquisition of new equipment � Innovative delivery models � New surgical and anesthetic techniques � Improved Discharge Planning
Wait Time Incremental Cases Challenges � Fixed funding (no COLA), one year only � Short notice period � Cannibalization Need to focus on other system priorities � � Clawbacks for unmet targets � Requirement for additional IT infrastructure and data collection
Innovative Delivery Models � High Volume Cataract Centre � Total Joint Assessment Centre
Cataract High Volume Centre � Partnership between North York General Hospital, Markham Stouffville Hospital, Humber River Regional Hospital � Dedicated ophthalmology operating room suite � Goal: work in partnership to improve access, and reduce wait time
Cataract High Volume Centre � Objectives: � Reduce the wait time for patients from to the time of decision to treat by an ophthalmologist to time of surgery � Improve access - increase the number of surgical cases performed � Improve operative efficiencies (standardization) � Improve patient outcomes
Cataract High Volume Centre Accomplishments: Cross-credentialing � Standardized work processes (operative packs, instruments, � supplies, forms) Process re-design � Implementation of alternative care providers � Effective buy-in � � No threat to referral patterns � No threat to number of cases (financial impact) Significant reduction in wait time for cataract surgery �
Cataract High Volume Centre Next Steps � Comprehensive eye care plan for the Central LHIN � Base volume cataract surgery consolidation � Scheduled non-cataract surgery � Urgent non-cataract surgery
Cataract High Volume Centre Challenges � Change management � New environment � New Team � Fee schedule – premium lenses
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