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The Integrated Operations Center (IOC)
An Operational Environment that supports teams in providing Quality Patient Care
What is our Integrated Operations Centre?
Concept
Place
Purpose
People
What Measurable Outcomes has it had?Acute patient journey - 6 hour target > 90% for 15/19
mnths – a sustained improvement
Cared for 875 more acute patients YTD (4% increase YonY) while maintaining bed utilisation at 2008 levels by a reduction in ALOS, nos. of LOS outliers and improvements in discharge by 11 (using the transit lounge) and weekend discharges
For the three months November to January we have been able to successfully keep closed 44 beds at Tauranga Hospital, and allow more staff to take annual leave over the summer/ school holiday, an have ongoing reduced occupancy
In 2009 – 2011 we had the Perfect Storm..
MOH 6 Hr Target expectations
MOH Safe Staffing Healthy Workplaces – Care Capacity Demand Management trial site
Air New Zealand Integrated Operations Centre visits
What do High Risk and High Performing Orgs have in Common?
And need to Minimise Variance
Variance creates a productivity ‘black hole’Risky! -increases patient risk and
decreases quality of care
Unsatisfactory -stressful and unsatisfactory for staff
Unproductive! -diverts significant resource away from frontline care
Hospitals are High Risk Organisations with Significant Daily Variance at the front door
60
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/01/
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/01/
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/05/
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/11/
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10
Tga ED Presentations Jan-Dec 2010
Added with Growth in Demand..
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Q1_2004Q2_2004Q3_2004Q4_2004Q1_2005Q2_2005Q3_2005Q4_2005Q1_2006Q2_2006Q3_2006Q4_2006Q1_2007Q2_2007Q3_2007Q4_2007Q1_2008Q2_2008Q3_2008Q4_2008Q1_2009Q2_2009Q3_2009Q4_2009Q1_2010Q2_2010Q3_2010Q4_2010Q1_2011Q2_2011Q3_2011
2004 2005 2006 2007 2008 2009 2010 2011
ED Attendances (Excl DNW)
TGA
WHK
How do we achieve Safe Quality Care even on a busy day?
Identify causes and address constraints
Minimise and manage variation
Predict demand
Match demand with capacity
Methodology of the IOCOperations Management Principles –
forecasting, planning, demand-capacity matching
Think system-wide, not silo
Visibility of operational status
Data-driven
Yesterday-Today –Tomorrow
Aiming for a Learning Organisation
• Assessing resource requirements• plant• people• supply chain• budget
• People fit for purpose• Working systems• Smoothing variability• Information • Environment fit for
purpose
• Forecasting demand
• Estimating capacity
• Setting organisational goals
• Delivering effective services to patients
• Managing residual variance without compromising productivity
• Information4.
DELIVERING
1. FORECASTI
NG
2. MATCHIN
G
3. ESTABLISHI
NG
PatientMonitoring Responding
SSHWP Model
IOC Roadmap
Agreement on a
Shared Vision
Confirm membership of CCPG (Plus the project plan)
Communication Plan - Social
Movement / Culture Change
·AirNZ Visits, CCDM Think Tank, Vision Forum – COO, DON, Medical and Nurse Leaders, IT, DSAs, Non Clinical Support, SIU, Allied Health, Radiology
·Agreement to jointly proceed with IOC and CCDM project plan and confirm membership for governance overview for the process of change
·Resource commitment including training and education for CCDM members and others.
•Set up Steering group , agree TOR
•Communication on initiative to staff
•A culture change/ social movement targeted. Confirm change management and communication strategy
The 6 IOC Work Streams
Co-location of
Operations Staff
Forecasting and
Planning / CCDM
“Status at a
Glance” Data
Views
Daily IOC Meeting SOPs
Working Relationships
Face to face problem solving
Innovation over the cooler
Staffing units :RMO unit RN Bureau Admin BureauOrderlies and security
CoordinatorHospital Coordinator Duty ManagersEmergency Planners
From data bases - TrendCare, Webpas
Proving to be very accurate
Allows for Evidence based planning and staffing
Built within the organisation, cost effective
Organisation wide visibility and understanding/ awareness
IT harnessed the data to increase understand around what is happening
Scheduled work visible to all
Enables early identification of exceptional circumstances
Enables informed conversations across key groups for problem solving
Operational oversight
11.30am Daily Operations Team Meetings - MDT, Whole of Hospital focus Operational decisions not made in isolation
Yesterday, Today, Tomorrow Improvement Model
VRM / CCDM
Each team develops a VRM.
Provide framework and context for escalation care capacity decision-making
A live document
ED SOP Developed (Northland DHB)
Acute Patient Journey SOP developed
Reflects patients location and stage of journey
Whole of hospital agreement
A live document
Forecasting
5 years of data
Proving to be accurate
Source, local data bases, Trendcare
Allows for base line planning
Staffing to need (evidence based)
Built within the organisation, cost effective
Standard Operating Procedures -SOPs Agreed Response Plan in advance with Front Line Staff and
Service Leaders Standard Operating Procedures (SOP) – Agreed Business as
Usual patient flow processes Variance Response Management Plans (VRM) – Essential Care
Protocol
On the Day SOPs used predominantly to unblock process constraints SOPs are developed and proposed in response to lessons
learnt and evidence from the yesterday, today, tomorrow cycle VRMs are used when capacity and demand move into a
mismatch
Its about what's best for the patient and how the organisation can organise capacity to best deliver this
CCDM - Matching Resource
Mix and Match – HIA, medical floors, ED, APU
Staffing to forecasting
Capacity management - 3A closed, CSU open
Medical resource in APU
SOP
Julie Chapman Learnings/ ActionsFri Sat Sun Mon Tue Wed Thu Fri Yesterday Fri Sat Sun Mon Tue Wed Thur Fri
6 Hr: 74% 91% 77% 87% 90% 94% 93% 100% 100% 100% 100% 100% 98% 100%ED presents fcast 118 109 131 122 120 110 105 118ED Presentations: 121 107 111 124 118 116 104Acute/arr ad fcast 54 32 30 56 51 59 54 54Acute/arr Admits: 47 25 29 52 47 47 40% Admitted via ED 39% 23% 26% 42% 40% 39% 35%Elective Admits 8/3 0 2/1 12/1 10/2 7/5 13/4 2/2Discharges fcast 64 24 20 55 56 61 56 64Discharges Actual 67 32 15 51 77 63 64Discharges Pred TC 23 9 10 14 19 22 26 26
Today Est. Dchges
Occ at 1100 low 14ED
Staffing Variance
RMO
Acute OT
CT/US
General X ray/Fluoro
A. Health
Clerical Support
Hosp.Supp.Svcs.
Exp. Discharges Tomorrow:
ED
Staffing Variance:RMO
Acute OT
RadiologyA. Health
Hosp.Supp.Svcs.
2692% fine
Safety Watches
Tomorrow
3 in w/r.
695 mins on board. 2nd acute OT on
12 pts waiting for CT, some OP CTs deferred
level of confidence in power board 50%. Non essential on temp board until essential circuits moved over. Reduced
lighting/power rad/basement. No impact CT. Next Sat 24th 0700 north
power local transformer cut to trans to board. Outage of about 5 mins x 2 to
liven temp board B. level of confidence then 80% Longer outage for migration
to be planned meeting next week. St Patricks day Sat.
Whakatane
Daily Operations Meeting Date: 16/3/2012 1130.
Good ED performance, numbers to prediction
Surg CME day, therefore possible capacity to close beds later today or over weekend ? 1d to close if
possible
95%
Yesterday
redeployment/ SW covering within. Sick calls x 3 so far fro pm, nasty cold doing the rounds
Weather
Flow and LOS Initiatives and Impacts
EDD on Trendcare and WardViewCNS stream in EDAppropriate use of OBSIncreased APU capacity with chairs,
APU RegAllied Health Weekend TrialPhlebotomy Rounds earlierTransit lounge surge capacityAcute response by IP teamsRed Triangles Ward ViewStructured Daily Meetings on Ward
Nek Minute - VRM
Variance Response
Management
What does Care Capacity Variance look like?
There is the capacity available to offer more health care to more people
The capacity is about right to efficiently provide quality care which demands reasonable work effort
Safe effective care can be provided with extra work effort and some change to how care is organised
The ability to provide safe care is at risk. Care is being rationed. Resources are being diverted away from direct care and into service rearrangement
Care and safety are being compromised. The system is gridlocked. Resource attention is being directed at the system rather than the care
Variance Response Management Matrix
Mauve Green Yellow Orange Red
Exec. Management
Service Leadership/Ops Management
Ward Unit
1. The Variance status (Colours) are defined; Mauve Extra capacity Green Capacity matches demand Yellow Early variance Orange Significant care capacity deficit Red Critical care capacity deficit.
Ward/Unit Variance Response Action PlanMauve Green Yellow Orange Red
NursingCNM/Delegate determines plan for the shift and communicates with Duty Manager
Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.Review patient management plans.
Offer staff for period available (e.g. 1 hour, 2 hour, 4 hour, meal relief, full shift).
Staff maybe directed to area of greater variance in cluster.
Review staffing for next 24hrs.
Pull patients in from other areas (e.g. outliers or ED)
If staff not required, consider offering annual leave or time in lieu (if owing).
Consider quality improvement activities
Ensure appropriate timely referrals to Allied Health
CNM/Delegate determines plan for the shift and communicates with Duty Manager
Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.Review patient management plans.
Escalate to medical team any patients not seen in last 24hrs.
Staff maybe directed to area of greater variance in consultation with Duty Manager.
Review staffing for next 24hrs.
Consider capacity to ‘pull’ patients in from other areas (e.g. outliers or ED)Consider quality improvement activitiesEnsure appropriate timely referrals to Allied Health
CNM/Delegate determines plan for the shift and communicates with Duty Manager.
CNM remains on the unit.
Consider reallocating staff to balance skill mix across floor
Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.
Review patient management plans.
Escalate to medical team any patients not seen in last 24hrs
Repatriation of patients to other facilities.Identify patients who could be put in to the lounge to await discharge.
Review staffing for next 24hrs.Reassess status in 1 hour
As per Yellow plus:Notifies Duty Manager and requests specific resource eg additional staff or admit stop.CNM take on floor co-ordination role.Consider overtime, extended shifts and/or calling in part time staff.CNM considers utilisation of all staff present e.g. orientation staff and students.Ensure ward/unit MDT are aware of status.Consider notifying Nurse Leader.Put agreed care rationing measures in place including rounding.Compile activity sheets for staff coming to assist for short periods.Ensure patients and on-ward relatives aware of status.Reassess status in 1 hourComplete Reportable Event form (REF) inclusive of Trendcare variance.
As per Orange plus:Mandatory reporting to Duty Manager and, Nurse Leader.
CNM to arrange for staff to stop all non clinical activities, e.g. cancel staff training.
CNM take on floor co-ordination role.
Implement “admit stop’Put ‘life and limb’, agreed care rationing measures in place including rounding.
Reassess status in 30 minutes
And so how does the IOC relate to the MOH 6 Hr Target….
The IOC provides for a targeted focus on patient flow:
Patient flow -variation and constraints on the day
When the planets align - 95%!!
When they do not – we identify which planet
Initiatives are live evidenced
Impact of change is monitored live
Variance in the Daily 6 Hr Target Performance
What enabled the IOC implementation?Having a whole of hospital shared vision
Leadership by senior management and clinical leaders
Hearing concerns to the fullest and champions addressing them
Working hard on awareness across the organisation – social marketing
Proactive implementation – whole of hospital
Positive OutcomesOrganisational ability to learn, and translate into
actionIOC operational staff report enhanced problem
solving - face to faceConversations are informed by Status at a Glance
screens - scene setting Silos reduced for operational decision makingWorking in the “tomorrow” and less surprises
todaySOPS - shared understanding Variance Response - unified language using the
‘colour’ systemTransparency between departments - visual
picture of the organisation statusTimely Data EntryDeveloping trust – bridging gaps
The FutureHospital Dashboard, Hospital Schedule,
Electronic Whiteboards
What else would staff find useful?
GO TEAM nominated Awards, Making Change that Matters Competition
Mechanism to identify Patients at Risk
Trendcare Patient Pathways
Awaiting VRM audit results