Care Redesign: A Report From the WSHA – NWONE Taskforce

1. Care Redesign: A Report From the WSHA – NWONE Taskforce Jon Smiley, CEO Sunnyside Community Hospital Gladys Campbell, RN, MSN Executive Director NW Organization of Nurse Executives & Nurse Leaders

2. How We Do Business….A Little Historical Context Crimean War Memorial

3. Today’s “War”… • Increasing cost • Increased number of uninsured • Public concern about errors, quality & transparency • Access challenges / divert • Healthcare workforce crisis

4. The Centrality of Nursing to the Workforce, Quality & Cost Concerns • Nurses make up 54% of the healthcare workforce • Labor is the most significant portion of a hospital’s operational costs • Nursing is usually about 50% of the labor cost • Emerging research links the quality of nursing care and the volume of nursing care hours to “untoward patient events” and even to mortality

5. 2000 US RN Supply/Demand Projectionsfrom HRSA “What is behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses. bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm

6. Percent of RNs Working in Hospitals (US) Declining in rural and urban areas

7. Nurse Sensitive Outcome Measures • Those patient outcomes that have been found, through research to have a direct and significant link to volume of nursing hours and quality of nursing care • Patient falls • Pressure Ulcers • Nosocomial infections – (post operative infections, pneumonia & urinary tract infections) • GI Bleeding • Cardiac Arrest (failure to rescue) • Increased mortality

8. How Nurses Currently Spend Their Time • 30% of time spent in direct care • Majority of time spent in • Documentation • Hunting and gathering for both supplies & information • Medication administration

9. What Picture Does this Paint? • Inefficient use of our most expensive resource • Union and staff unrest • A future where we will not have the number of staff we currently “need” • Research evidence that links low volume nursing care with “untoward events” • CMS regulations that won’t pay for these events

10. So What Do We Do? “There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction” John F Kennedy

11. So What Do We Do? • The situation begs for a new way of thinking about how we do business… • A transformation is needed to • Deliver care with increased efficiency and effectiveness & to do that with less staff • We need care givers to spend more direct time with patients • We need to allow care givers to function to the full limits of their licensure

12. The Literature on Care Redesign • Literally hundreds of articles and research papers have been written in the last 20 years on health care redesign.

13. How the Literature “Clusters” Redesign of Work Culture Redesign of Work Spaces Redesign of Work Processes Redesign of Care Delivery Models

14. Why System and Process? • Significant time spent hunting and gathering • Only 30% of nursing time spent in direct care • 20 seconds in one place

15. System and Process Redesign • Lean processes • Six sigma analysis • Time motion studies • Studies of waste • Implementation of technology

16. Why Physical Geography? • Walk as much as 3 miles a shift • Nurse isolation • Patient transfers: • Create significant workload • Disrupt caregiver-patient relationships • Reduce continuity of care • Creates dangerous patient “hand-offs”

17. Physical Geography Redesign • Acuity adaptable rooms allow for limited patient transfer • Clusters or cells optimize “sight lines” and foster small cohesive teams • “Hunting and gathering” is minimized • More time is spent in direct patient care

18. Why Models of Care Delivery? • Increased complexity of care • Lower volumes of available nurses • Few nurses with higher education levels

19. Models of Care Redesign • Masters prepared nurse is team leader or clinical nurse leader • Work in small “cell” groupings of acuity adaptable rooms • Work with lesser educated RNs, new graduate RNs, nurses aides, care technicians & other disciplines to care for an assigned group of 10 – 12 patients

20. Why Cultures of Care Delivery? • Shared values, norms, assumptions • Complex, yet simply how employees perceive an organization • How their perception causes patterns of belief, values, & expectation • Specific characteristics include: • Style of management • Sense of hierarchy • Decision making authority • Communication patterns, perception of who has “a voice”

21. Organizational Culture Redesign • Autonomy • Participative management • Respected leadership: open and transparent communications • Support for professional development • Relatively high organizational status of nursing • Adequate resources • Collaboration and teamwork • Support for continuity of care

22. Our Response >> • Presentations at the August WSHA Board Retreat: • Health Workforce Institute • Quality and Safety Committee • NWONE • Requests from the WSHA members, after the retreat to move forward on a redesign proposal

23. Our Response >>The WSHA – NWONE Taskforce on Care Redesign • Task Force Members • Joe Kortum & Gladys Campbell, Co-Chairs • Joe Kortum & Dan Kereti - SW Washington MC • Rod Hochman & Traci Hoiting – Swedish • Sarah Patterson & Charleen Tachibana – VM • Nancy Steiger & Faye Lundquist – St. Joseph • Dave Brooks & Kim Williams – Prov Everett • Jon Smiley & Nancy Hultberg – Sunnyside • Diane Cecchettini & JoEllen Vanatta – Multicare • Jack Evans & Tracy Kasnick – Central Washington Hospital • Stan Johnson & Frankie Manning - VA

24. The Redesign Taskforce Charter • Goal – “Recognizing that there will inevitably be a shortage of clinical personnel available in the near future, the group plans to initiate a 2 phased project to define & test both individual hospital redesign strategies & shared strategies to: • Attract & retain clinical staff • Increase time in direct patient care • Enhance clinical quality and safety • Enhance staff and patient satisfaction

25. The Redesign Taskforce Charter • Expected Outcomes: Complete a formal written proposal outlining a process to: • Encourage all Washington hospitals to engage in creative redesign strategies • Create a “learning collaborative” where learnings from redesign efforts can be safely shared • Define two processes for redesign • A single hospital rapid cycle approach • A multiple hospital “demonstration project” aimed at testing specific defined interventions the 4 areas of “bundled” redesign – geography, systems & processes, models of care & cultures of care • Define the metrics which will be used to measure the success of redesign efforts

26. The Two Approaches to Redesign • Rapid Cycle Improvement • The testing of individual hospital based improvements, one at a time, where outcomes & experiences can be shared • Specific evaluation and metrics will be used to assess outcome

27. The Two Approaches to Redesign cont. • Demonstration Project • A group of hospitals working together to implement a set of uniform pre-determined interventions based on the 4 foci of redesign (geography, systems, models of care, culture) • Utilization of a controlled “test” environment or incubator into which the interventions can be implemented across multiple & varied settings, & outcomes measured • The process would include specific controls and expectations for alignment • The process would be overseen by a Project Director • Participants in both approaches would participate in “learning collaboratives” so that we might learn from each others experiences.

28. Measurement Metrics • The goal is to use measurements that most all hospitals are already using in the areas of: • Quality • Satisfaction • Finance • Examples might include: • CMS, JC and NQF data • ADC, ALOS, OT use, Agency use, Turnover & vacancy rates • Patient, staff and physician satisfaction

29. Opportunities for Participation • As many hospitals as interested • Willingness to collect data • Participate in a protected “learning collaborative” • Early access to interventions with measurable improvement • Role in developing, testing and sharing local, and potentially national “best practice”

30. The Radical Change Required for Redesign will Also Require New Thinking……

31. The Leadership Required for this Redesign will also be Demanding… There are many people who think they want to be matadors only to find themselves in the ring with two thousand pounds of bull bearing down on them and then discovering that what they really wanted was to wear tight pants and hear the roar of the crowd. Terry Pearce

32. So.. What are your thoughts & questions? And now are there any questions?? • Is this work you would participate in? • What are the unique challenges for re-design in rural areas? • What redesign initiative might specifically fit the rural healthcare community?