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

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Implementing Process Redesign Strategies for
Improving Hospital CareShinyi Wu,
PhDAssistant Professor, Epstein Department of
Industrial and Systems Engineering University of
Southern California and RAND

• September 15, 2009, presented at AHRQ Conference

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AcknowledgementCo-authors, Sponsor, and
Participants

• Marjorie Pearson, PhD, _at_ RAND
• Lisa Smith, RN, BSN, BS, _at_ UHC
• Raj Behal, MD, MPH, _at_ Rush University Medical
  Center
• Julie Cerese, RN, MSN, _at_ UHC
• Helga Brake, PharmD, CPHQ, _at_ Northwestern
  Hospital
• Joanne Cuny, RN, BSN, MBA, _at_ UHC
• Ryan Mutter, PhD, _at_ AHRQ
• Michael Harrison, PhD, _at_ AHRQ
• The participating healthcare organizations

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

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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. DemandSupply

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24/7 Redesign Strategies

• Four demand and a customized supply best
  practices
• Developed from the NHS model, literature review,
  and advisory group recommendations

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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

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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 InterventionsCreate an
Implementation Plan for each intervention
























Performance Improvement Model





Step 3







Implement Interventions Execute activities and
implement best practices



























Step 4






Measure Results, Analyze Data, and Act on Results




Step 5













Standardize Communicate










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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
• Demandsupply 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

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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 4 5
Measure and analyze 3 10
Act on results 2 4
Measure, analyze, standardize communicate 10 45 (38)
Total 24 81
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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.
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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

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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

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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

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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?