60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: 905 948-1872 Fax: 905 948-8011 Toll Free: 1 866 392-5446 www.centrallhin.on.ca Emergency Department Quality Collaborative: Improving Quality in Emergency Departments by Enhancing Flow Context Executive Summary October 13, 2011 The Ontario government is moving forward with a comprehensive strategy to improve the quality and accountability of the health system. The Excellent Care for All Act, 2010 (ECFAA) received Royal Assent on June 8th, 2010, and is key enabling legislation for this strategy. In alignment with the province s quality direction, and to advance quality at the local system level, the Central Local Health Integration Network (LHIN) has been implementing a local quality approach and leading efforts to define a provincial role for LHINs in supporting this work. Key initiatives have been designed around building quality improvement capacity, and include Central LHIN s Quality Symposium Patients First: Creating Quality in the Transitions of Care and other engagements, such as the recent Improving Quality in Emergency Departments by Enhancing Flow Quality Collaborative and the Central LHIN-Hospital Quality Improvement Plan engagement session. Community engagement brings visibility to the importance of partnership building and offers a venue for the LHIN and health service sectors to work together, exchange knowledge and information, and collaborate in a meaningful way around quality improvement. Key recommendations flowing from these recent engagements, which align with the Central LHIN Quality Action Plan, highlight the need to identify specific opportunities for collaborative engagement related to quality indicators where improvement has been identified as necessary. In particular, exploring flow initiatives and how these could be optimized to improve outcomes, reduce patient wait times and improve length of stay was identified by Central LHIN hospitals as a key area of focus for a quality collaborative. Collaborative Purpose/Objectives While a range of strategies have been implemented across the province to support achievement of Emergency Department (ED) wait time targets (e.g. Pay for Results, ED Process Improvement Project, or ED-PIP), Ontario hospitals continue to face challenges in this area, especially for patients who require admission. Central LHIN performance for this specific wait time indicator has also been consistently above the provincial average for some time. 1
Research from Canada, Australia and the United States suggests that ED wait times and delays to treatment contribute to increased morbidity and mortality, particularly for time-sensitive conditions such as pneumonia. On September 22, 2011, Central LHIN brought together clinical and administrative representatives from all acute care hospitals in the LHIN and the Central CCAC to attend Improving Quality in Emergency Departments by Enhancing Flow: An Emergency Department Quality Collaborative. The Collaborative s learning objectives included the following: Review Central LHIN performance data related to ED wait times, with a focus on length of stay for admitted patients; Identify potential solutions that have been successful in other jurisdictions to reduce ED wait times and length of stay, with a focus on organizational change management; Prioritize key elements, challenges and opportunities to achieve quality improvement in this area for Central LHIN hospitals; and Identify roles for, and obtain the commitment of, physicians and hospital administration. The Collaborative sought to explore the linkages between longer lengths of stay and patient quality/ outcomes with the goal to identify organizational and system wide strategies for improvement. The Collaborative also provided an opportunity to hear examples of change initiatives that are sustaining positive results in the system. The session is the first in a series of Quality Collaboratives being implemented as part of the Central LHIN Quality Action Plan. Discussion Summary The session began with opening remarks from the Collaborative moderator, Dr. Joshua Tepper, Vice President, Education, Sunnybrook Health Sciences Centre. Dr. Tepper provided an overview of the critical role that EDs play in supporting health system performance, and reminded the group that patient experience in the ED is often the litmus test for how people judge overall health system performance. Kim Baker, Chief Executive Officer, Central LHIN, then delivered a Call to Action for improving quality and patient outcomes. She reviewed LHIN and hospital performance data pertaining to the length of stay for admitted patients, and reflected on recently published research linking length of stay in ED to increased mortality and poorer patient outcomes. Following the opening remarks, Central LHIN invited presentations on success stories from three Ontario hospitals that had significantly improved ED wait times and length of stay. It is notable that these improvements were achieved despite consistently increasing ED volumes. Implementing Corporate Patient Flow Initiatives First, Dr. Richard Bowry, Medical Director, Corporate Patient Flow Performance Portfolio, St. Michael s Hospital, shared the results of their Corporate Patient Flow Initiative. In 2011, St. Michael s Hospital was the recipient of a 3M Health Care Quality Team Award for the work of their Corporate Patient Flow performance team, which undertook a system-wide internal change management process to catalyze improvement in patient flow and access. Through this initiative St. Michael s Hospital was able to reduce admitted patients waiting for greater than 24 hours by 75%, and improve emergency department length of stay for admitted patients by 48%. 2
St. Michael s initiated this strategy in 2008/09 that put patients at the center of quality improvement, defining the scope of patient flow as from when the patient leaves home to when a patient gets home. Part of the new strategy included the establishment of a corporate definition of quality, which the hospital defines as: safety, outcomes, access, patient experience, efficiency and equity. The hospital set out five activity streams through which the Corporate Patient Flow Initiative would achieve its mandate: 1. 2. 3. 4. 5. Corporate level programming policies, guidelines, performance measures and targets and a communications strategy; Daily operational facilitation of adoption peer to peer facilitation/troubleshooting and monitoring compliance and a liaison for the CCAC; Local level programming rapid process improvement action groups; Organizational capacity building developing and embedding a culturally-oriented and bundled change management/process improvement approach; and External partnerships and knowledge transfer. Three key themes drove improvement at St. Michael s Hospital, including: Sharing information and providing feedback daily reports, updated measures and case reviews with triggers for action; Visual management tools and streamlined protocols pathway to discharge toolkit, patient process flows and use of intranet performance reporting systems; and A common quality improvement approach multidisciplinary action groups and a shared quality improvement methodology. Through the quality improvement cycle, clinical staff became the champions of organizational change. The chart for every patient whose length of stay exceeded 18 hours in the ED was reviewed to identify opportunities for improvement. The hospital also created a Patient Flow Advisory Council that included shared accountability for performance improvement with individuals from across the organization and participation from senior leadership who created corporate polices to support the staff and team. Implementing a Medical Admission & Consultation Unit In the second presentation, Dr. Roshan Shafai, Chief of Medicine, Southlake Regional Health Centre, spoke about the hospital s implementation of its Medical Admission & Consultation Unit (MACU). Southlake s MACU approach significantly reduced the number of patients waiting in the emergency department; reduced typical length of stay by 33% in 2011/12 (year to date); increased patient satisfaction survey excellent scores by 7%; and decreased patient complaints by 38% during a time where medicine volumes were up by 11%. Patients that received frontloaded care from the MACU had inpatient lengths of stay 2.5 days less on average than comparable patients that did not flow through the MACU. The key objectives of the MACU were to: 3
Streamline and expedite rapid and comprehensive assessment for acute medicine patients including a plan of care; Provide early and appropriate diagnostic testing, clinical investigations and reporting to optimize patient flow; Achieve early consultations by specialists; Improve linkages with community partners, including primary care; and Standardize processes and care delivery model with role descriptions for the dedicated MACU team. Southlake Regional Health Centre was an early adopter of this model, which utilized a rapid inpatient treatment area that frontloaded patient care following admission with enhanced case management and priority access to diagnostic imaging. The MACU is dedicated for patients who are expected to be discharged within 48 hours; is attended by internists; and is staffed by a dedicated multidisciplinary team. The MACU has case managers involved from the start of admission. In addition to the improvements noted above, the hospital has been able to decrease the time to physician initial assessment due to the streamed admission process. Southlake has also found efficiency gains in the ED due to improved patient flow. Implementing a Medicine Short Stay Unit The third presentation was delivered by Carmine Stumpo, Acting Vice President, Patient Programs, Toronto East General Hospital (TEGH). Mr. Stumpo provided an overview of the hospital s Medicine Short Stay Unit (MSSU). Within several weeks of the implementation of the MSSU in May 2011, the hospital achieved a reduction in time to decision to admit from 16 hours to below the 8 hour target. To support implementation, TEGH created a dedicated, flexible, multidisciplinary team that combined emergency and medicine staff. The MSSU, located in a physically distinct location within the hospital, was split into two separate units an express admission unit designed for individuals with lengths of stay under 4 hours, and a short stay unit for individuals with lengths of stay of under 72 hours and utilized an assistant located in the ED to pull patients appropriate for the MSSU out and assign them to the unit. The hospital integrated information management supports into the team. Daily huddles and weekly scrums were used to review performance. The hospital created an integrated structured approach utilizing LEAN methodology. Important performance metrics were measured and reported weekly in run charts. Some of the key measures included were time from decision to admit to patient in in-patient bed, length of stay of short stay patients (less than 72 hours), and the volume of patients moving through the unit. Since the implementation of the MSSU, the time from decision to admit to an in-patient bed dropped significantly and the approximate volume of patients coming through the MSSU increased from 40% of admissions to 70%. Key success factors for the MSSU included: Integrated structured approach bringing emergency and medicine staff together; The use of LEAN methodology; Having it in a physically distinct location within the hospital; and Timely reporting and feedback on performance metrics. 4
Panel Discussion The Collaborative then moved into a panel discussion with six senior hospital leaders who offered their reflections on specific hospital strategies/tactics being employed to drive improvement, with a focus on internal hospital change management. The six panel participants were: Helena Hutton, Vice President, Quality, Southlake Regional Health Centre Francis Reinholdt, Operations Director, Emergency, Medicine and Critical Care Programs York Central Hospital Gary Ryan, Chief Executive Officer, Stevenson Memorial Hospital Mary Lynne MacMaster, Director, Patient Experience and Quality, North York General Hospital Julia Scott, Vice President and Chief Nursing Executive, Markham Stouffville Hospital Barbara Willitts, Program Director, Acute Medicine and Emergency Services, Humber River Regional Hospital The panelists were asked to: Share the successes, challenges and next steps regarding a specific initiative their hospital is pursuing / has pursued for ED wait times for admitted patients, or on an ED-specific initiative related to their hospital s focus for improving quality and patient safety. Describe what is needed or what works to mobilize, change, and maintain a call to action, for example, an internal hospital commitment, providers, departments and governance oversight. And to consider: o What idea at the Collaborative was most important to tackle first? Why? o What idea would be easiest to address first? Why? o What would require more time and resources to address? Why? o How they would focus the change management internally? The panelists reflected on both challenges and opportunities. Included below are many of the common themes identified: Panel Discussion Challenges & Opportunities Organizational issues related to patient flow need to be acknowledged by senior leaders of the organization, who need to support change while also empowering front line staff to own and drive change; Normalization of less optimal performance can be mitigated through setting corporate strategic goals that focus on patient flow, patient satisfaction and quality (i.e. positive deviance). Performance metrics should be reported frequently and be visible (such as through the use of ED tracking boards); Peer to peer performance comparisons is crucial because it highlights areas and teams in need of improvement, initiating and sustaining change; Multidisciplinary teams are key and must include alignment of ED with internal medicine department; Culture change is essential because it builds the foundation to sustain change and allows the identification of the essential ingredients to change for the organization; 5
Recognition that solutions to improving patient flow are complex, and quality improvement is a continuous cycle; and The use of LEAN or other quality improvement methods to support improving processes. Next Steps/Our Commitment Summary At the conclusion of the Collaborative, each participant was asked to reflect upon three key questions in support of advancing performance improvement on these issues within their own organization and in collaboration with the LHIN. The questions asked were: 1. Identify three key areas of focus to drive improvement within your hospital (i.e. how can we do better) 2. For each of the suggested initiatives, identify who needs to be involved and what their roles should be (i.e. Hospital CEOs, clinicians, hospital administration, Central LHIN, etc.) 3. Identify what processes and structures can be leveraged to support these improvements? a. Existing working groups (i.e. ED working group, Clinical Services Planning group, etc.) b. A new collaborative working group c. Webinars/teleconferences Central LHIN thanks Collaborative participants for their extremely thoughtful feedback. Below is a summary of the key themes derived from review of written comments from the participants: Strategic Alignment and Performance Achieving quality improvement requires alignment of strategies at the corporate (health service provider), LHIN and system level. System improvement requires inter-organizational collaboration hospitals and other health service providers must work together to solve challenges related to patient flow as well as clear and broad articulation of system performance improvement objectives (by the LHIN). Organizational Culture Change Fostering organizational culture change is necessary to create an environment for successful quality improvement. This should include empowering front line teams to identify issues and take ownership of solutions. Role of Clinicians Engagement of clinical hospital staff in designing and implementing quality improvement strategies is essential, particularly representatives from the hospitalist / internist teams. Hospital primary care groups and chiefs of staff should also be represented in these discussions. New initiatives may be supported by existing structures/processes such as the ED working group, and the ALC / Rehab Task Force. 6
Focus on the Transitions of Care CCACs, primary care, and community mental health support services should be consulted/involved in all hospital quality improvement initiatives and must have aligned strategies to improve quality of care across the continuum. Reducing avoidable readmissions to hospital should be a key aim of all health service providers. Cross-LHIN collaboration More collaboration to support continuous quality improvement is necessary across the system. A key role for LHINs is to facilitate knowledge exchange and transfer across organizations in the local health system. This should include improving cross-lhin repatriation agreements. Cross LHIN collaboration is critically important also, particularly in the GTA where patient s utilization of, and transition across, multiple LHIN providers, occurs frequently. Going Forward Collaborative Action Team As a key next step, and as informed by the Collaborative feedback/key themes, Central LHIN proposes to leverage its current structures to bring together an action-oriented team to support driving effective and sustainable improvement on length of stay for admitted patients in Central LHIN hospitals. This team will provide regular progress updates to the LHIN/Hospital/CCAC CEO Group. Membership will be drawn from existing Central LHIN working group participants (including ED/ALC Advisory Network, ED Working Group, Clinical Services Planning Group, etc.), and also include key representation from other stakeholders (e.g. hospital ED Chiefs of Staff, internal medicine, primary care, etc.). Continuing collaboration between Central LHIN and health service providers is critical to the success of this initiative. The team will work together to review and address current challenges surrounding length of stay for admitted patients in each hospital with the goal of spreading improvement opportunities throughout these organizations and ultimately achieving progress to improve results. As an immediate next step, in preparation for the first meeting of the team, each hospital will be asked to undertake a chart review/outcome determination of those patients who waited in the ED longer than 90 hours in Q1. The team will also create a terms of reference to guide their work and create measures of success. It will outline a clear set of goals, milestones, roles and responsibilities and reporting/relationship structures. This report and its key themes is a component of the Central LHIN Quality Action Plan. In addition to being shared with all Collaborative participants, the final report will be provided to other key stakeholders, such as the MOHLTC, and will also be posted on the Central LHIN website. Evaluation An evaluation survey was distributed to all participants to gather their perspectives and feedback on how to improve future engagement sessions. Evaluation feedback showed strong support for the Collaborative model, with the majority of participants indicating that it provided value for the health service providers in attendance, and a request for the LHIN to facilitate more similarly structured sessions. Suggested future topics included ALC and further discussion on the creation and use of inter-professional care models. 7