September 15, 2009, presented at AHRQ Conference 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 September 15, 2009, presented at AHRQ Conference

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

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

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. Demand+Supply 4

24/7 Redesign Strategies: Four “demand” and a customized “supply” best practices Developed from the NHS model, literature review, and advisory group recommendations Customized staffing supply Discharge planning Structured Handoffs Paging Policy Common Complains PRN Medications

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

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 Interventions Create an Implementation Plan for each intervention Performance Improvement Model Step 3: Implement Interventions Execute activities and implement best practices Improvement? Yes: Step 5 No: Step 2 Step 4: Measure Results, Analyze Data, and Act on Results Step 5: Standardize & Communicate

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 Demand+supply 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

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 5 Measure and analyze 10 Act on results Measure, analyze, standardize & communicate 45 (38) Total 24 81

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.

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

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

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

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?