Canada’s First Accountable Care Unit:An Interdisciplinary Approach to Inpatient Care

Alana Morrissette BSc MPTPhysical TherapistSaskatchewan Health Authority

Dr. Ron Taylor MD CCFP (EM) FCFPHospitalistSaskatchewan Health Authority

Alana MorrissetteHas received honorarium to present with 1unit in Virginia and Minneapolis.

Ron TaylorHas received honorarium to work with 1unit in Indianapolis and Brisbane.

Disclosures

1. Identify the 4 features of an ACU

2. Identify how the ACU model addresses barriers to interdisciplinary care

3. Discuss how Structured Interdisciplinary Bedside Rounds, a distinguishing feature of an ACU, have improved patient care and satisfaction

Objectives:

Who has experience in an inpatient setting either as an employee or as a patient/family member?

How was the experience?

Reflection

Getty Images (2019). Bed on Hospital ward. [Photograph]. Retrieved from https://www.istockphoto.com/fi/photo/bed-on-hospital-ward-gm160950983-23030572

What changes would you like to see in the way that care is delivered in hospitals?

Discussion

Trust Life & Investments (2016). Introduction to Private Treatment [Photograph] Retrieved from https://www.trustlife.ca/services/group-benefits/landscape-1446811092-g-introduction-to-private-treatment-78606057/

Traditional Hospital Care

Traditional Hospital Dialogue

When will my dad be discharged from hospital?

Are we starting the patient on those antibiotics?

Did we get weight bearing orders for the patient yet?

The patient isn’t mobilizing because of pain, can he get a different medication?

Can my dad still go back to his care home?

National Public Radio (2014). In the Hospital, A Bad Translation can Destroy a Life [Photograph]. Retrieved from https://www.npr.org/sections/health-shots/2014/10/27/358055673/in-the-hospital-a-bad-translation-can-destroy-a-life

Traditional Hospital Communication

PT OT SW Nurse Physician

SLP Dietitian Family Patient Pharm.

Traditional Hospital Communication

PT OT SW Nurse Physician

SLP Dietitian Family Patient Pharm.Face-to-Face

Phone Call

WrittenPage

Written

Phone Call Written

Phone Call

Written

Traditional Hospital Communication Mishaps

•Waiting by a phone for 20 minutes for a page to be returned

•Patient in agonizing pain while nurse awaits medication orders

•Polypharmacy resulting from patients’ discharge prior to pharmacy review

Traditional Hospital Communication Mishaps

•Staff transferring patient with a mechanical lift rather than patient standing to a walker since therapy notes were not reviewed

•Patient not mobilizing since therapist awaiting activity/weight bearing orders

•Patient spending extra days in hospital to “improve walking” when therapy notes indicated patient’s baseline involved the use of a total lift and wheelchair

Traditional Hospital Care : Two Words

Complex

Devised

Groups of clinicians and staff working together on a regular basis, and in a defined setting, with a shared clinical purpose to provide care for a population of patients.

Effective Clinical Microsystem (Barach, 2006)

To be effective a clinical microsystem requires clinical objectives, linked processes, a shared information environment, and measurable performance outcomes.

Effective Clinical Microsystem (Barach, 2006)

Better Together

1Unit (2019). Rely on Each Other [Video]. Retrieved from https://1unit.wistia.com/medias/7lkznp503d?wvideo=7lkznp503d&wemail=CanadaJune2019

https://1unit.wistia.com/medias/7lkznp503d?wvideo=7lkznp503d&wemail=CanadaJune2019

1. Unit based teams: physicians’ patients located on a single ward A small group of people who work together on a regular basis, and in a defined setting, while providing patient care.

2. Routines: daily interdisciplinary bedside round Linked processes in a shared information environment

3. Nurse/ Physician Co Lead UnitService and Care aims

4. Unit-specific performance reportsMeasurable performance outcomes

Four Features of an ACU

Physicians’ Normal

1. Physicians’ Patients Located On the Same Ward

7G

7G

7G

7G

7G

5B

ER

1. Physicians’ Patients Located On the Same Ward

6G

7G

5G

2G

HG

ACU NormalSNAFU

1. Physicians’ Patients Located On the Same Ward

“Geographic alignment fosters mutual respect, cohesiveness, communication, timeliness, and face-to-face problem solving, and has been linked to improved patient satisfaction, decreased length of stay, and reductions in morbidity and mortality.” (Stein et al, 2015)

2. Routines – linked care processes

Bed Management

Touchpoint

Team Huddle

AHO

SIBR

Bed Management

Touchpoint

Debrief

Bed Management

Touchpoint

Team Huddle

AHO

A day of routines24 hour cycle

2. Routines – linked care processes

SIBR

StructedInterdisciplinaryBedsideRounds

whiteboardNurse

MD

Pharmacist

Structured Interdisciplinary Bedside Rounds (SIBR) 4A

SW

Medication Safety Opportunities:a. Medication discrepancies to

resolveb. Potential ADEs c. Antimicrobial to narrowd. IV to oral switchese. Vaccinations

1 min

3 mins

Confirms Plan for Discharge:a. Home environment/family

involvement b. Next site of carec. Discharge needsd. Anticipated Date of Discharge

Rounds Manage

r

Manage SIBR Roundsa. Ensure next bedside nurse ready for SIBR

teamb. Updates TDD and SCM

5. Invite inputs from allied healtha. Pharmacist, Social Worker, OT/PT, Dietitian

6. Synthesize plan using all inputsa. Propose plan for the day & assign responsibilitiesb. Propose plan for discharge

□ Discharge needs & next site of care□ Anticipated day of discharge(TDD0

c. Acknowledge team member inputs and concernsd. Thank patients and family for their time

< 30 seconds

2 mins

Start Time: @10:00 & @11:00 Duration: ≤60 mins

Patient

Family

< 30 seconds

3. Update current status a. Overnight events & Patient’s goal for the dayb. Vital signs & Pain controlc. Fluid status & nutritional riskd. Urine & bowel outputse. Mental Statusf. ADLs and mobility

4. Review Quality-Safety Checklist� Foley Catheter necessity� IV or Central line necessity� VTE Prophylaxis in place � Pressure ulcer/skin� Glycemic control

< 15 seconds

< 45 seconds

OT/PT

Dietitian

Update Statusa. Best baseline statusb. Current mobility & goal statusc. Support needs for discharge

Update Status a. Current statusb. Concerns &

needs

1. Introduce a. Lead team into room, greet patient & familyb. Introduce self, prompt team members to do same

2. Update hospital course a. Review active problems and response to treatmentb. Discuss interval test results/consultant inputsc. Invite inputs from patient and family, then nurse…

< 15 seconds

< 45 seconds

SIBR

MD

1. Introduce a. Lead team into room, greet patient & familyb. Introduce self, prompt team members to do same

2. Update hospital course a. Review active problems and response to treatment

b. Discuss interval test results/consultant inputsc. Invite inputs from patient and family, then nurse…

SIBR

Nurse

3. Update current status a. Overnight events & Patient’s goal for the dayb. Vital signs & Pain controlc. Fluid status & nutritional riskd. Urine & bowel outputse. Mental Statusf. ADLs and mobility

4. Review Quality-Safety Checklist� Foley Catheter necessity� IV or Central line necessity� VTE Prophylaxis in place � Pressure ulcer/skin� Glycemic control

< 15 sec

< 45sec

SIBR

5. Invite inputs from allied healtha. Pharmacist, Social Worker, OT/PT, Dietitian

MD

SIBR

Pharmacist

Medication Safety Opportunities:a. Medication discrepancies to resolveb. Potential ADEs c. Antimicrobial to narrowd. IV to oral switchese. Vaccinations

PT/OT

Update Statusa. Best baseline statusb. Current mobility & goal statusc. Support needs for discharge

SIBR

Dietitian

Update Status a. Current statusb. Concerns & needs

SW

Confirms Plan for Discharge:a. Home environment/family involvement b. Next site of carec. Discharge needsd. Anticipated Date of Discharge

SIBR

Rounds Manager

Manage SIBR Roundsa. Ensure next bedside nurse ready for SIBR teamb. Updates TDD and SCM

6. Synthesize plan using all inputsa. Propose plan for the day & assign responsibilitiesb. Propose plan for discharge

□ Discharge needs & next site of care□ Anticipated day of discharge(TDD)

c. Acknowledge team member inputs and concernsd. Thank patients and family for their time

MD

Physical Therapist SIBR Script

• Duration of PT involvement

• Baseline mobility

• Current/barriers to mobility

• Therapy goals prior to discharge

• Estimate of sessions required prior to discharge

Video Clip of SIBR

3. Co-Management

“Effective leadership is a major driver of successful clinical microsystems” (Stein et al, 2015)

The co-leadership pair fills a management gap. These coleaders play an essential role in building momentum for the structure and processes of the ACU.

4. Unit Specific Performance Measurement

68.9

33

68.4

35.9

62.6 61.4

95

41

79

34

8292

0102030405060708090

100

9 hospitalsRegina

Pneumovax

More2Eat

Chart1

Screened for Nutrition RiskScreened for Nutrition Risk

Identified at Nutrition RiskIdentified at Nutrition Risk

SGA completedSGA completed

MedpassMedpass

Body weight measuredBody weight measured

Food intake monitoredFood intake monitored

9 hospitals

Regina

68.9

95

33

41

68.4

79

35.9

34

62.6

82

61.4

92

Sheet1

9 hospitalsRegina

Screened for Nutrition Risk68.995

Identified at Nutrition Risk3341

SGA completed68.479

Medpass35.934

Body weight measured62.682

Food intake monitored61.492

To resize chart data range, drag lower right corner of range.

4. Unit Specific Performance Measurement

Why do patient’s have a better experience

Reductions in - Mortality- Complications of care- Length-of-stay- Costs

Improved - Patient satisfaction- Staff satisfaction- Teamwork

Mortality

Patient Experience

Reactive Care

Physician

??

??

?

?

?

?

?

?

?

Proactive Care

Reactive care vs Proactive care

ACU

ACU

The Impact on Physical Therapy

Barriers to PT Intervention in Acute Care

• Inappropriate referrals • Ambiguous/illegible physician orders • Infrequent patient mobilization• Poorly communicated discharge plans • Inadequate pain management • Insufficient staffing • Etc.

Reactive care vs Proactive care

Reactive Care

Inappropriate ReferralsJustifying importance of mobilizationChallenge with ordersModifiable Impediments to MobilizationInfrequent MobilizationNeedless Patient DeteriorationLimited Accountability

Indiscriminate consultsMobilization by PT onlyNon-specific progress

Functional decline

“Normal”

Reactive care vs Proactive care

Appropriate referralsTeam educates & promotes mobilizationClear physician orders within minutesAddressing modifiable impedimentsPatient & staff engaged mobilizationAppropriate equipment in set locationsIncreased # PT sessions per dayShared accountability for progress

Proactive Care

Staff Engagement

Staff Engagement

Notes from a physician after the weekend

Staff Engagement

Physician: “Now that you’re mobilizing, we can remove the foley catheter.”

Physician: “It sounds like you have really improved. Maybe we can discharge you sooner than next Friday. Let’s aim for Tuesday instead.”

Social work: “If the patient’s wheelchair has been ordered, I can ask the husband to pick it up when I speak with him this afternoon.”

PT: “I’m so glad my patient transferred to your unit. I couldn’t get orders on the other unit.”

How Can A High Functioning ACU Foster Continuous Improvement?

Communication changes from….

Traditional Hospital Communication

PT OT SW Nurse Physician

SLP Dietitian Family Patient Pharm.Face-to-Face

Phone Call

WrittenPage

Written

Phone Call Written

Phone Call

Written

ACU Communication

Ongoing, energetic face-to-face communication between the interdisciplinary team, patient & family throughout the day(Stein et al, 2005)

Physician

Nurse

Pharmacist

Therapists• PT• OT• SLP

Dietitian

Social Worker

Patient/ Family

Staff Perspective

Family Perspective

Questions?The goal isn’t to preserve the system. It should be to solve a problem regardless of the system, even if that means throwing out the system. Improving should be our priority.

Dr. Peter Pronovost

ContactDr Ron Taylor

Ron.taylor@saskhealthauthority.ca

Alana Morrissette

Alana.morrissette2@saskhealthauthority.ca

mailto:Ron.taylor@saskhealthauthority.ca

References

Barach, P., Johnson, J.K. (2006). Understanding the complexity of redesigning care around the clinical microsystem. Qual Saf Health Care, 15(1), i10-i16.

Gausvik C., Lautar A., Miller L., Pallerla H., Schlaudecker J. (2015). Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. Journal of Multidisciplinary Healthcare, 14, 33–37.

O’Leary K.J., Buck, R., Fligiel, H.M., Haviley, C., Slade, M.E., Landler, M.P., Kulkarni, N., Hinami, K., Lee, J., Cohn, S.E., Williams, M.V., Wayne, D.B. (2011). Structured interdisciplinary rounds in a medical teaching unit: Improving Patient Safety. Arch Internal Medicine, 11(171), 678-684.

Stein, J., Payne, C., Methvin, A., Bonsall, J.M., Chadwick, L., Clark, D. (2015). Reorganizing a hospital ward as an accountable care unit. J Hosp Med, 10, 36–40.

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