National Emergency Medicine Programme Implementation Update November 2012 These slides provide an overview of: ED and LIU pathways (slide 2) ED patient pathway developments recommended in the EMP Report 2012 and First Steps document. Emphasis is on local adaptation of model to meet patient needs (slides 3 to 5) EMP Implementation Approach (slide 6, 10, 11) Clinical Microsystems (slides 7, 8, 9) Diagram illustrating Emergency Care as a complex adaptive system (slide 12) Factors to consider in implementing large scale health system change (slides 13, 14) Path ahead (slide 15) Cut and paste, amend and adapt as appropriate to your ED team 1

Patient Pathways – ED and LIUs Emergency Medicine Programme ED Arrival Seen by treating clinician Disposition Decision Disposition Decision Completion Admitting team S/B Admitting Team ED Departure Rapid Access OPD Specialty Assessment/Admission Units GP Access to Diagnostics Registration Triage ED Arrival Seen by treating clinician Disposition Decision Disposition Decision Registration ED Pathway of care LIU Pathway of care 2

Arrival to seen by treating clinician Arrival Seen by treating clinician Registration Triage Mini-registration Work-redesign Mini-registration Work-redesign Advanced Triage Advanced Triage RAT ECG Front-load blood tests Supply analgesia Mental Health Decision Tool MTD Assessment Frail Elderly ECG Front-load blood tests Supply analgesia Mental Health Decision Tool MTD Assessment Frail Elderly MTS only Standardised triage Demand capacity analysis Monitor effectiveness Pain assessment Infection Prevention & Control MTS only Standardised triage Demand capacity analysis Monitor effectiveness Pain assessment Infection Prevention & Control Assess peak demand Staffing resource Share protocols Assess peak demand Staffing resource Share protocols Streamin g ANP stream Fast track Monitoring Protocol Monitoring Protocol Ambulance Handover Evidence Based Pathway of care EMP Report 2012 Chapter 19 & references 3

Condition Specific Pathways Condition Specific Pathways Sharing effective practice Patient Pathway Emergency Medicine Programme4 Seen by treating clinician Disposition Decision Disposition Decision Monitoring Protocol Monitoring Protocol ANP stream Medical Workforce Medical Workforce Clinical Guidelines Clinical Guidelines Access to Diagnostics Review with results Process Efficiency Initiatives Process Efficiency Initiatives Protocol for patients who leave before completion of treatment

Patient Pathway Emergency Medicine Programme5 Disposition Decision Disposition Decision Completion Admitting team Assessment Completion Admitting team Assessment S/B Admitting Team ED Departure Direct ward admission protocol Transition of care protocol Process efficiency initiatives Bed management CDU protocols Data capture Diagnostic coding

EMP Implementation Approach What changes are needed to implement the EMP in our ED? How do we make the change happen and sustain improvement? Clinical Microsystems EMP First Steps Emergency Care System Safe, high-quality reliable, resilient patient care and clinical teams 6

Sustainable Improvement Triangle Emergency Medicine Programme “The combined and unceasing efforts of everyone - health care professionals, patients and their families, researches, payers, planners, educators – to make the changes that will lead to bettter pateint outcomes, better system performance and better professional development (learning new knowledge, skills and values).” Better Professional Development (competence, pride, joy) Better Outcome Patient, Population (health status, patient experience, illness burden) Better System Performance (quality, safety, value) Everyone Batalden Davidoff Sustainable Improvement Triangle: Sustainable efforts in real settings require inextricable linkages 7

What are Clinical Microsystems? The clinical microsystem is where care is “made”. It is at this level that quality, safety, reliability, efficiency and innovation are created along with staff morale and the patient experience. PatientProvider Information All other components of the health system exist to support the clinical microsystem. for further information and resources. 8

Dartmouth Microsystems Improvement Curriculum for Emergency Departments AssessmentDiagnosisTreatmentFollow-upLead Team Set up Team Set up ED COG Decide way of working Set objectives Baseline Analysis - ED Attendance Data - ED Profile Analysis - Purpose definition - Survey patients, staff, team skills, activity; Process Mapping Patterns Analysis Activities Demand/capacity planning Strengths/weakness analysis Lean/Six Sigma approaches Value stream mapping Prioritisation matrix Implementation plan Plan-Do-Study-Act Lean 5-S Other improvement tools Lessons Learned Use ED COG for Continuous Improvement Cycle Steps 9

Implementation Support Approach Knowledge & Ideas Context Outcomes Stan Strengthening Governance, with defined roles and meetings structure Knowledge, best practise and experience sharing through website, meetings and seminars Training in quality improvement including microsystems, effective meetings, process improvement etc. Detailed, on -the- job coaching to train entire ED team and embed approach within unit Standard metrics and data base lining Continuous Quality Improvement Actions 10

Putting it all together Ongoing improvement ECN Infrastructure, workforce, Intelligence, resouces. First Steps ED Clinical Operational Groups, EMP Implementation Teams and Programme Support EMP Outcomes Measurement (using baseline data) EMP Report 2012 Patient participation and feedback Implementation support from hospital, region, HSE, SDU, DOH Clinical Microsystems Improvement Approach Building a foundation for sustained improvement National Initiatives (e.g. datasets, EDIS, Emergency Care Networks) Achieving EMP aims for patients, staff and the health system 11

Ambulance service ED Workforce Nursing, medical, others Skill-mix Agency/locums/overtime etc. Quality of care Evidence based, cost-effective care Patient experience Process efficiency Patient outcomes, safety, risks ED infrastructure to match demand Access to diagnostics for ED discharges CDU care reducing LOS Linked Emergency Care Network Units Hospitals for escalating levels of care Primary & Community care Patients Volume of demand Time distribution of demand Complexity of casemix Acuity of casemix Age profile Patient perceptions & preferences System Intelligence Data capture – EDIS Outcomes measurement Process measurement Cost capture, allocation and management Acute Hospital Supporting on-site specialties and services Work practices Access to diagnostics In-patient bed capacity, utilisation & access A Complex Adaptive System 12

Improving a Complex Adaptive System Improvement science learning points: Create the conditions for improvement and change Try not to increase the chaos in the system e.g. by introducing changes that are not aligned with overarching goals Command and control approaches are less likely to lead to sustainable change – flexibility, small tests of change and a ground-up approach are more likely to be effective Actions: Set strategic goals and align improvement to the goals Provide essential infrastructure to support improvement Track priorities Test changes at local level Spread and sustain improvement Get everyone involved Ensure accountability 13

Organising Quality Health Care Six Universal Challenges for Health Systems that Seek to Organise Quality Health Care* applied to EMP Implementation ChallengeDescription StructuralStructuring, planning and coordinating implementation actions PoliticalNegotiating the politics of change with all stakeholders, getting buy-in, building change relationships, dealing with opposition, agreeing to a common adenda for improvement CulturalBuilding shared understanding and commitment EducationalSharing and embedding knowledge and continuous learning, improvement skills and expertise EmotionalSupporting enthusiasm and sustaining momentum and motivation Physical and technologicalDesign and implement a physical, information and technology infrastructure that improves service quality and patient experience These challenges exist at ED, hospital, network and national level. *Bate P et al. Organising for quality: The improvement journeys of hospitals in Europe and the United States. Radcliffe Pub

The Path Ahead National Level: HIQA Tallaght Report Implementation EMP - sharing effective practice; models of care; supporting implementation teams SDU / DOH/HSE – Creating the environment for implementation – capacity, focus, priority – Hospital and regional support – Workforce issues within emergency care Local level (customise as appropriate) 15