The New Normal

International Clinical Operations Board

The New Normal

Redesigning Care Around Complex Multimorbid Patients

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Executive Summary ...... 6

Advisors to Our Work ...... 7

Introduction: A System in Trouble...... 11

Chapter 1: Encourage Clinicians to Share Information Effectively ...... 25

Tactic 1: Institution-Wide Commitment to Team-Based Care ...... 30 Tactic 2: Required Interprofessional Training for Clinicians...... 36 Tactic 3: Nurse Evaluations of Doctor Performance ...... 39

Chapter 2: Employ a New Type of Team Leader ...... 43 Tactic 4: Hospitalists: In-Hospital Generalist Decision Makers...... 49

Chapter 3: Construct Reliable Group Decision Processes ...... 77 Tactic 5: Structured Interdisciplinary Bedside Rounds (SIBR®) ...... 84 Tactic 6: Case Review Conferences...... 93

Special Report: Patients: The Untapped Resource...... 101

Conclusion: The Missing Piece of the Puzzle...... 117

Templates and Tools...... 121

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Complex Multimorbid Patients: The New Normal Looking back at the efficiency work done in hospitals over the last decade, be it in the emergency department or at discharge, a common theme emerges: successful patient flow management requires a focus on complex multimorbid patients to prevent them from experiencing delays and setbacks in their hospital journey. As this patient population grows in number—becoming the new normal—hospital executives must consider efforts to redesign hospital operations around their needs, rather than simply sending in special teams to provide intensive support in an attempt to avoid this population’s impact on flow within specific process bottlenecks.

While global efforts to better manage these patients in the community and thereby avoid hospitalisations altogether are underway, hospital executives must recognise that those efforts may in fact expedite the need to redesign care within the hospital. Better population health management efforts may reduce unnecessary admissions and readmissions, but these efforts can only hope to slow, not reduce, the need for additional hospital beds given the ageing (and sickening) population. And in fact, successful community care initiatives will continue to move more straightforward care, currently provided in hospitals, outside, leaving behind the sickest and most complex patients for the hospital.

Redesigning Acute Care Around Complex Patients Unfortunately, the modern hospital cannot efficiently and effectively treat this modern patient. The processes that successfully moved more straightforward cases through the hospital now leave complex patients languishing. An increase in the number of conditions each patient has, coupled with a proliferation of specialised care team members, has made care provision extremely complicated to coordinate in a timely, effective way. Hospitals must transform how they approach inpatient treatment processes to better manage care for patients with multimorbidity.

Identifying the Root Cause: Inefficient and Ineffective Decision Making Improving care team collaboration, let alone complex patient care, is a broad goal, and one that is challenging to know how to tackle. At its core, the collaborative care process required for complex patients is only as good as the decisions the team makes—these decisions should be the focus of hospital efforts to improve complex patient care.

This research presents hospitals with the three major opportunities available to improve the speed and quality of patient care decisions. First, decisions must be based on accurate and timely information. Hospitals need to improve how clinicians seek out and share information with each other. Second, decisions must be clearly owned by the correct decision maker. Complex patient care is often led by a clinician that does not have the clinical knowledge to fully manage treating multimorbidity. Finally, there must be opportunities for clinicians to collaborate on decisions when necessary. Too often the structures in place for in-person collaboration and decision making are suboptimal or nonexistent.

Taken together, these strategies will help hospitals to transform their inpatient care to be fit for the patient of the future: the complex patient.

The Clinical Operations Board With Sincere Appreciation research team is sincerely grateful AUSTRALIA Tracey Peadon Royal Children’s Hospital to those who shared their insights, Joanne Uttley Nicki Mountford analysis, and time with us. We ACT Health Mark Wilson would especially like to recognise Heather McKay St. Vincent’s & Mater Health the following individuals and Ian Thompson Darling Downs Hospital Carolyn Marsh organisations for being particularly and Health Service Anthony Schembri generous with their time and Cabrini Health Peter Bristow Bree Nation Sydney Adventist Hospital expertise. Natalie Sullivan Epworth HealthCare Jeanette Conley Julia Trimboli Sharon Donovan Brett Goods Michael Walsh Louise O’Connor Lena Jowett Simon Woods Genie Pedagogos MaryAnne Noonan Ross Penman Cairns and Hinterland Hospital Mid North Coast Moran Wasson Health Service Local Health District Paul Cullen Helen Byrnes The Townsville Hospital Madeleine Downey Kathleen Ryan and Health Service Donna Goodman Judy Morton Eddy Strivens Orange Health Service Darryl Mackender Victorian Department of Health Calvary Mater Newcastle Susan Patterson Brigid Clarke Roslyn Barker Gabriel Shannon Simone Corin Cathy Fraser Children’s Health Queensland Peter MacCallum Cancer Centre Helen Smallwood Yervette Jones David Speakman Shelley Nowlan Western Australia Princess Alexandra Hospital Department of Health Clinical Excellence Commission Dawn Bandeira Elizabeth Rohwedder Clifford Hughes Janet Hardwick Peter Kennedy Sally Taranec Western Health John Sammut Alex Cockram Wilson Yeung Queensland Health Garry Lane Veronica Casey Joy Macdonald Coffs Harbour Health Campus Sandy Moss Denise Patterson Theresa Beswick Arlene Wake Sergio Diez Alvarez

Western Sydney Hospital Albert Einstein Horizon Health Network Sault Area Hospital Local Health District Leonardo Brochado da Silva David Kogon Nancy Richer Jennifer Fitzsimons Miguel Cendoroglo Neto Margaret Melanson Lindsey Gough Nancy Parker The Hospital for Sick Children Yogendra Narayan Hospital Dos Fornecedores de Cana Natalie Wiggins Karima Karmali Miki Mochizuki Kate Langrish BELGIUM Interlake-Eastern Regional Hospital Nove de Julho Health Authority The Ottawa Hospital Centre Hospitalier Inter-Regional Edith Adriano Machado Blair Stevenson Alan Forster Cavell Carlos Nassif Jack Kitts Jacques de Toeuf Regina Tranchesi Niagara Health Gilbert Bejjani Cami D’Uva The Scarborough Hospital Hospital Pro-Cardiaco Joanna Mataya Jennifer Istvan CHU de Liege Daniel Bezerra Rhonda Seidman-Carlson Jean-Marie Boulanger Northern Health Vedu Tadiboyina Hospital Samaritano Joanne Cozac Nancy Veloso Jessa Hospital Dante Gambardella Angela De Smit Yves Breysem Simone Teixeira Julie Dhaliwal Vancouver Coastal Health Neil Evans Sara-Grey Charlton Hôpitaux Iris Sud Hospital São Francisco Abu Hamour Deb Halket Philippe Vandenbergh Silvia Fonseca Kendra Kiss Scott Harrison Michael McMillan Margot Wilson Universitair Ziekenhuis Gent Hospital Sirio Libanes Sherri Tillotson Luc Herregods Luiz Cardoso William Osler Health System Jose Mauro Vieira Queen’s University Stephen Chin BULGARIA Vandad Yousefi Karen Dang CANADA Jane deLacy City Hospitals and Clinics Queensway Carleton Hospital Kiki Ferrari Mina Popova Bluewater Health Kent Woodhall Naveed Mohammad Lynda Robinson BRAZIL Royal Victoria Regional Children’s Hospital of Eastern Ontario Health Centre A.C. Camargo Cancer Center Pat Elliot-Miller Lindsey Crawford Jarbas J. Salto, Jr. Hugo Lemay Nathalie Major Saskatoon Health Region Complexo Hospitalar Sao Sandra Blevins Bernardo do Campo Health Sciences North Daniel Beltrammi David McNeil ©2015 The Advisory Board Company 31972 8 advisory.com Advisors to Our Work (cont.)

CHILE FRANCE NEW ZEALAND NORWAY

Clínica Alemana de Santiago Aga Khan Health Service Auckland District Health Board Helse Sør-Øst RHF Bernd Oberpaur Sisawo Konteh Margaret Dotchin Ole Tjomsland Nadim Mawji Andrew Old COLOMBIA Fahmia Mehdi Richard Summers Sykehuset Ostfold Sulaiman Shahabuddin Marit Flåsker Clínica León XIII Zeenat Sulaiman Cantebury District Health Board Lina María Estrada Nigel Millar Sykehuset i Vestfold Oscar Hernández Muñoz GERMANY Siri Vedeld Hammer John Jairo Tamayo Counties Manukau District Evangelisches Krankenhaus Hubertus Health Board PERU Fundación Cardioinfantil Matthias Albrecht Ria Byron Carlos Vicente Arteta Molina Renee Greaves AUNA Oncosalud IRELAND Brad Healey Fernando Suazo Fundación Cardiovascular Gloria Johnson de Colombia St. Patrick’s University Hospital Ian Kaihe-Wetting Clínica Anglo Americana Elsa Serpa Paul Gilligan Denise Kivell Gabriela Arboleda Ruben Vargas Jim Lucey Cassandra Laskey James Castle Lynne Maher Moraima Custodio Hospital de San Jose MEXICO Geraint Martin Gisella Neira Luis Alberto Blanco Bev McClelland Hugo Siu Diana García Quintero The American British Cowdray Medical Richard Small Center I.A.P. Clínica Ricardo Palma FINLAND Yadira Hernández Lakes District Health Board Sebastián Céspedes Lesley Yule Juan Ponce de Leon Etelä-Karjalan Sairaala NETHERLANDS Sarah Vega Lauri Lammi Mercy Ascot ZGT Almelo Maree Cassidy Keski-Suomen Nel Nienhuis Geoff Sparkes Keskussairaala-Jyväskylä Vesa Kataja Vilans Taranaki District Health Board Ruth Pel-Little Elizabeth Disney

SAUDI ARABIA Central Manchester University Royal Bolton Hospital Veterans Affairs Eastern Colorado Hospitals NHS Foundation Trust NHS Foundation Trust Health Care System, CO King Fahad Medical City David Evans Andy Ennis Mel Anderson Ahmed AlOmair Imelda Hughes Bronwyn Kerr Taunton and Somerset 1Unit, GA SWITZERLAND Jon Simpson NHS Foundation Trust Jason Stein Martin Vernon Peter Campbell Centre Hospitalier Peter Lewis Universitaire Vaudois Epsom and St Helier University Jean-Blaise Wasserfallen Hospitals NHS Trust The Princess Alexandra Anne-Claude Griesser Jackie Sullivan Hospital NHS Trust Shahid Sardar Hôpitaux Universitaires de Genève Ipswich Hospital NHS Trust Mathieu Nendaz Viv Barker UNITED STATES Arnaud Perrier Sarah Higson Jane Shoote Abington Health, PA Inselspital Universitätsspital Bern Diane Humbrecht Monika Brodmann NHS Borders Aristomenis Exadaktylos Evelyn Rodger Emory Healthcare, GA Hal Jones THAILAND Northern Devon Healthcare NHS Trust Pinnacle Health System, PA Bumrungrad International Hospital Rob Sainsbury Nirmal Joshi Mack Banner Northern Health and RAND Corporation, MA UNITED KINGDOM Social Care Trust Mark Friedberg Helen McClurg Abertawe Bro Morgannwg Saint Francis Hospital and University Health Board Northumbria Healthcare Medical Center, CT Hamish Laing NHS Foundation Trust Surendra Khera Vanessa Bainbridge John Rodis Cambridge University Hospitals Jim Mackey NHS Foundation Trust Derek Thomson Keith McNeil

A System in Trouble

Perfecting patient flow continues to be Complex Patients the Common Thread Amongst Patient Flow Studies the most requested topic of Clinical Operations Board members. To date, the Board’s research has looked at capacity overall and helped to alleviate Recent Clinical Operations Board Publications pressure on specific bottlenecks across the patient’s acute care journey: whether relieving pressure on an overcrowded emergency department; planning for an earlier, more effective 2015: The Emergency 2013: The Discharge 2011: Seamless Care discharge; or promoting seamless care Care Strategy Guide Strategy Handbook Transitions transitions to prevent unnecessary readmissions. Example Practice: Example Practice: Example Practice: Complex Needs Specialised Planning for Patient Risk Assessment When this research is taken together, a Coordination Team Specialised Care and Intervention clear pattern emerges: improving patient flow hinges on improving care processes for complex patients.

The best hospitals therefore have Addressing Complexity a Necessary Component of Process Improvement specific strategies to segment complex patients out and provide more intensive To solve capacity and quality problems, hospitals must improve processes for complex levels of care to this smaller group to patients. Improvements are made by identifying high-risk, complex patients and scaling help streamline patient flow. resources to match their needs.

These practices are very effective— they target the problem.

Source: Advisory Board interviews and analysis.

For example, Sanford Medical Center, Sanford Medical Center’s Risk Stratification Approach for Complex Discharge Planning a US-based hospital, used a 1 segmentation approach that remains LACE: Length of stay, Acute admission, Comorbidities, Emergency department visits one of the Clinical Operations Board’s most popular and powerful practices. Normal Discharge Bedside Discharge Interdisciplinary Through the use of the LACE risk Planning Planning Care Conference algorithm, defined at right, Sanford was able to risk stratify patients into Caregivers review Frontline nurse, social Includes stakeholders cohorts, providing increasing levels of discharge plan outside of worker, and case manager from external organisations, care based on a patient’s risk of patient’s room identify barriers to scheduled for family readmission. discharge and interventions participation at patient’s bedside Given limited resources, the interventions typically used to improve All patients care for complex patients are too time and resource intensive to be applied Patients with across all patients. Patient >10% but <20% segmentation allows organisations to probability of readmissions use their limited resources on the patients most likely to benefit from Patients with higher-intensity interventions. ≥20% probability of readmissions This practice provides two important lessons. First, hospitals need to identify which patients are most complex. Second, hospitals need to use this Case in Brief: Sanford Medical Center – Fargo knowledge to scale high-intensity care • 447-bed hospital located in Fargo, North Dakota, US efficiently for only those patients that • Profiled in Clinical Operations Board study Seamless Care Transitions as Practice 2: Patient need it. Risk Assessment and Intervention • In September 2010, hospital automated calculation of readmissions risk using quantitative risk assessment to identify patients needing more intensive interventions • Based on probability of readmission, each patient placed into one of three stratified levels of readmissions risk, each with its own set of interventions

1) During previous six months. Source: Sanford Medical Center, Fargo, North Dakota, US; Advisory Board interviews and analysis.

While segmentation and scaling Increasing Number of Complex Patients Reducing Tool Sensitivity resources remain important strategies for improving patient flow, our research indicates that these practices are becoming less useful. The tools used Shift in Patient Mix and Intervention Needs to segment still work, but the patient population they are targeting is growing Normal Discharge Bedside Discharge Interdisciplinary Care so rapidly that they are losing their Planning Planning Conference filtering capability. All Patients Patients with >10% but <20% Patients with ≥20% probability of probability of readmissions readmissions Many organisations seem to be at a Distribution of tipping point, with hospital patient Patients When populations that are fundamentally Tool Developed more complex than they used to be.

Distribution of Patients Now

Two-Thirds of Health Spending Now on Multimorbid Patients

“The most common chronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions […] Adults with multiple chronic conditions are the major users of health care services at all adult ages, and account for more than two-thirds of health care spending.”

Designing Health Care for the Most Common Chronic Condition—Multimorbidity

Source: Tinetti, M, et al., “Designing Health Care for the Most Common Chronic Condition—Multimorbidity”, JAMA, 2012; Advisory Board interviews and analysis.

To a certain extent, the positive health Feeling the Shift Already care developments of the past decades have created a new challenge: patients are living longer with more and more Percentage of Australian Adults Projected Growth of People with 1 chronic diseases. A “simple” patient with Multimorbidity by Age Group Multiple Conditions in England with no complications or comorbidities is increasingly a thing of the past. 80% Indeed, as we look at demographic 66% 53% increase trends globally, populations and 2.9M hospital patient mixes are shifting, with 50% more and more patients falling into complex, high-resource categories. 1.9M

45-65 60+ 75+ 2008 2018

Percentage of US Hospital Patients with Major Complicating or Comorbid Conditions2

US Inpatients with US Inpatients with MCC3 in 2003 MCC in 2014

64% 78%

1) The prevalence rates for multimorbidity are gathered from multiple cross-sectional population studies. Source: Erny-Albrecht, K, McIntyre, E, “The Growing Burden of Multimorbidity”, PHCRIS Research Roundup 31, August 2013, 2) Defined as “Any combination of chronic disease with at least one other disease (acute or chronic) or http://www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/publications/pdfs/phcris_pub_8409.pdf; bio-psychosocial factor (associated or not) or somatic risk factor. Claudia S, et al., “Trends and Projections in Hospital Stays for Adults with Multiple Chronic Conditions, 2003–2014”, Agency 3) Major complications or comorbidities—as categorised through the Medical Severity—Diagnostic for Healthcare Research and Quality, 2014, http://www.hcup-us.ahrq.gov/reports/statbriefs/sb183-Hospitalizations-Multiple- Related Group (MS-DRG) classification system. Chronic-Conditions-Projections-2014.pdf; Advisory Board interviews and analysis.

While these patients consume more Hospital Admissions the Driver of Avoidable Costs for Multimorbid Patients resources than “simple” patients across the entire care continuum, the challenge for hospital executives in Increase in Odds of Having Four or more Percentage of Services Used by particular is that hospitalisations make Hospital Admissions a Year, per Risk Factor Long-Term Condition, UK up the lion’s share of this resource use. New South Wales Survey Data

And there’s a perception that many of 4.8 Type of Service these hospitalisations are in fact unnecessary—meaning they could be 3.9 18% 28% avoided altogether with better care 12% management in the community. 58% 2.7 14%

70% 12% 1.1 58% 0.9 30%

Number of ED Attendances Inpatient Bed Age Diabetes COPD Charlson Chronic People Days (75+ versus Comorbidity Heart 65-74) Score ≥ 3 Failure No LTC1 Non-limiting LTC Limiting LTC

Average Health and Social Care Cost by Long-Term Condition, UK GBP2 £7,600 £5,900 Average cost per person £3,000 per year £1,000

None One Two Three+

Source: Hewitson P, et al., “Long Term Conditions Compendium of Information”, NHS Department of Health, 3rd Edition, 2012, http://www.biomedcentral.com/content/pdf/1472-6963-14-33.pdf; Longman J, et al., “Frequent Hospital Admission of Older People with Chronic Disease: A Cross- 1) Long-term conditions that limit a person’s activities. Sectional Survey with Telephone Follow-Up and Data Linkage”, BMC Health Services Research, October 30, 2012, http://www.biomedcentral.com/1472-6963/12/373/; 2) British Pounds. Advisory Board interviews and analysis.

It’s perhaps not surprising then that Worldwide Experiments on Population Health Targeting Complex Patients governments and payers around the world are experimenting with new ways to better manage this patient population.

Population health experiments around Government Experiments to The Advisory Board’s the world are actively working to Promote Population Health Working Definition for Care Transformation provide better care for complex patients in the community, avoiding the England: Five Year Forward need for a hospital admission. View promotes New Care The attempt to encourage Models Programme—Vanguard These efforts are part of broader sites selected to integrate stakeholders to work together in attempts to enact care transformation, primary and acute care systems a person-centred approach to which focuses on better managing patients in the lowest-cost appropriate effectively treat patients in the Australia: Various NSW, setting to reduce both admissions and lowest-cost appropriate setting Victoria and other state readmissions. programs to shift post-acute and to reduce the need for care to community treatment in a population

US: Accountable Care Organisations—primary care providers assuming financial risk for a population of patients

Source: Advisory Board interviews and analysis.

Population health initiatives are Community Interventions Can Only Hope to Slow Need for More Beds fundamental to sustaining health systems in the long term.

Shown here in scenario 1 is an Theoretical Impact of Better Community Care on Hospital Volume and Case Mix illustration of what happens if governments and organisations do not Scenario 1: Current Course and Speed Scenario 2: Reducing Avoidable (Re)Admissions invest in population health: an unsustainable growth in hospital volumes.

The goal of population health efforts is to reduce the number of avoidable admissions and readmissions— reflected in the scenario 2 graph. Hospital Hospital Volume Volume Yet even in this scenario, successful initiatives slow, but do not reduce, overall hospital demand. Unavoidable Complex Admissions Unavoidable Complex Admissions For the hospital, this means the mix of 2015 2025 2015 2025 patients becomes even more challenging. ‘Easier’ patients are now treated more often in the community, leaving the hospital with the sickest— and most complex.

Hospitals therefore cannot rely on population health to totally solve internal pressures. Organisations must 2015 2025 2015 2025 take stock of current processes and determine whether they are prepared for a majority complex patient mix.

1) Admissions and readmissions that are medically necessary at the time of hospitalisation, but could have been prevented through better care management in the community. Source: Advisory Board interviews and analysis.

Complex patients are becoming the Current Model Bad for Patients and Caregivers Alike new normal. Unfortunately, our research suggests that many hospitals are currently struggling to effectively manage these multimorbid patients. Delays, Mistakes on Typical Complex Patient “Pathway”

More often than not, the complex patient’s hospital journey is Unidentified psychosocial Adverse drug event characterised by delays and mistakes issue forces care plan causes complication Treatment in treatment decisions, stemming from revision breakdowns in communication Referral to rehab lost in various between the various caregivers patient notes involved in their treatment. While these Admission patients need coordinated care the Recovery Discharge most, they are often the patients that receive it the least. Doctor doesn’t History taken three communicate Discharge delayed by times by different care plan to nurse deterioration of clinicians secondary condition

Not Very Good at Talking to One Another “Where we regularly fall down is with the highly complex patients that need to be treated by many different people. We really aren’t very good at talking to one another. We need to put infrastructure in place to ensure this always happens, especially with these highly complex patients. They need it the most, but typically get it the least.”

Executive Director of Nursing and Midwifery Services, Australian public hospital

Source: Advisory Board interviews and analysis.

Current care processes are suboptimal Current Practice Undermining Not Only Quality, but Also Costs for the care team as well—no hospital staff want to provide poor or slow care to their patients.

In fact, the challenges of poor 1 collaboration that characterise the Annual Economic Burden of Communication Inefficiencies complex patient hospital journey have Average 500-Bed Hospital very real costs associated with them.

As the data here shows, Cost of Wasted $0.3M communication inefficiencies alone can Doctor Time incur significant financial costs on top of the higher costs already associated with treating complex patients.

Cost of Wasted Cost of $4.6M $1.8M $2.5M Nurse Time Increased LOS Total annual costs attributed to inefficient communication for average 500-bed hospital

Source: Evanoff, B, et al., “Can We Talk? Priorities for Patient Care Differed Among Health Care Providers”, Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings), Rockville, MD: Agency for Healthcare Research and Quality, 2005 Feb; Agarwal R, et al., “Quantifying the Economic Impact of Communication Inefficiencies in U.S. Hospitals”, 1) US dollars. Journal of Healthcare Management, 2010, 55265-282; Advisory Board interviews and analysis.

Today’s care teams are struggling to Increase in Diseases per Person, Specialists per Disease effectively and efficiently treat complex patients for two interrelated reasons.

First, the hospital patient of today has more conditions than the patient of the past, inherently complicating the care Example of Increase in Treatment Complexity, 1985-2015 they require. A patient with more conditions needs more clinicians. Patient Clinicians Involved Collaboration Second, at the same time, clinicians have continued to specialise as our medical understanding of each condition has deepened over time, Cardiologist such that each condition may now 1 Nice to have 1985 Arrhythmia GP have multiple members of the care team dedicated to it. Unit Nurse

With a larger team, effective collaboration becomes both essential to have and much harder to achieve. … … Cardiologist Clinical Nurse Renal Dietician Specialist Arrhythmia Electro- Pharmacist

2015 physiologist Unit Nurse Critical, Depression Others… Nephrologist Psychiatrist must have Kidney Failure GP Clinical Social Worker

1) General Practitioner. Source: Advisory Board interviews and analysis.

However, improving care team Poor Decision Making at the Root of the Problem collaboration, let alone complex patient care, is a broad goal—almost too broad to effectively manage. Critical Barriers to Effective Acute Care for Complex Patients Our studies of this challenge suggest that the core operational problem in taking care of complex patients is achieving efficient and effective decision making. Delayed Decisions Suboptimal Decisions At its core, the collaborative care Inability to make care decisions Mistakes in care planning, caused process required for complex patients when medically necessary adds by incorrect or incomplete is only as good as the decisions the lag time to patient stay information, extend patient stay due team makes—these decisions should to unforeseen adverse events be the focus of hospital efforts to improve complex patient care.

A focus on care decisions is important for two reasons. Slow decisions add Clinical Decision Making a Complex Process unnecessary lag time between “Clinical decision making by health professionals is a more complex process, requiring components of the treatment process, more of individuals than making defined choices between limited options. Health hindering efficient patient flow. Poor professionals are required to make decisions with multiple foci (e.g., diagnosis, quality decisions, whether from intervention, interaction, and evaluation), in dynamic contexts, using a diverse knowledge incorrect or incomplete information, base with multiple variables and individuals involved.” can lead to mistakes in care that Factors Influencing Clinical Decision Making, Elsevier Health extend the patient stay’s and lead to subpar outcomes.

Source: Smith M, et al., “Chapter 8: Factors Influencing Clinical Decision Making”, Clinical Reasoning in the Health Professions, Third Edition, Elsev ier Health, 2008, http://www.elsevierhealth.com/media/us/samplechapters/9780750688857/9780750688857.pdf; Advisory Board interviews and analysis.

We suggest that hospitals have three major opportunities available to improve the speed and quality of patient care decisions. Three Opportunities to Make Better, Faster Decisions

First, decisions must be based on Good Decisions Are… accurate and timely information. Hospitals need to improve how Enhanced by collaborative clinicians seek out and share Based on accurate and Clearly owned by the timely information right decision maker input and thoughtful debate information with each other.

Second, decisions must be clearly owned by the correct decision maker. Complex patient care is frequently led by a clinician that does not have the clinical knowledge to fully manage the But Unfortunately… whole patient rather than a specific disease that patient has. Clinicians do not Suboptimal decision Poor structure for in-person effectively seek or share maker leading and group collaboration and Finally, there must be opportunities for information coordinating care decision making clinicians to collaborate on decisions when necessary. Too often the structures in place for in-person collaboration and decision making are suboptimal or nonexistent.

Source: Advisory Board interviews and analysis.

To redesign acute care around Creating an Effective Team-Based Approach to Care complex patients, hospitals will need to reexamine their decision-making processes and fine tune them for an era of hospital care in which large groups of clinicians care for patients. Building the Foundation Designing an Effective Decision Model This study is composed of three major strategies that map to the essential elements of good decisions discussed 1 2 3 on the previous page. Within each Encourage Clinicians to Employ a New Type of Construct Reliable Group strategy are tactics drawn from Share Information Effectively Team Leader Decision Processes hospitals around the world that have Page 25 Page 43 Page 77 succeeded in these particular areas.

While the primary focus of this study is 1. Institution-Wide Commitment 4. Hospitalists: In-Hospital 5. Structured Interdisciplinary to Team-Based Care Generalist Decision Makers Bedside Rounds (SIBR®) to improve the decision-making process among clinicians, it would be a Emory Healthcare, US i. Clínica Alemana, Chile Clinical Excellence Commission and Orange Health Service, mistake to omit a discussion of patient 2. Required Interprofessional ii. William Osler Health System, Australia and family as integral players in the Training for Clinicians Canada 6. Case Review Conferences decision-making process. The study Inselspital Universitätsspital iii.Saint Francis Hospital and therefore also contains a special report Bern, Switzerland Medical Center, US Adventist Medical Center, US looking at how hospitals can apply the 3. Nurse Evaluations of Doctor iv.The Mount Sinai Hospital, US Kaiser Permanente, US lessons of this study to better involve Performance patients and their families in that Hospital Israelita Albert Einstein, process. Brazil

Special Report Page 101 Patients: The Untapped Resource

Source: Advisory Board interviews and analysis.

Tactic 1: Institution-Wide Commitment to Team-Based Care Tactic 2: Required Interprofessional Training for Clinicians Tactic 3: Nurse Evaluations of Doctor Performance

Good decisions require accurate and Decisions Only as Good as the Information on Which They’re Based timely information. All too often, though, the information needed for a decision isn’t communicated well or is delivered too late to be useful. In fact, many of the adverse events that occur in hospitals have communication failure Negative Outcomes Associated with Poor Communication Between Clinicians as a root cause.

Effective communication is more important—and more challenging— when faced with the intricacies of Adverse Events or Close-Call 1 out of 2 treating complex patients with multiple 82% Reports That Cite Communication conditions. Failure as a Root Cause Communication failures in which timing of an exchange was requested or provided too late to be useful

Communication, Collaboration Essential “During the course of a four-day hospital stay, a patient may interact with 50 different employees, including physicians, nurses, technicians, and others. Effective clinical practice thus involves many instances where critical information must be accurately communicated. Team collaboration is essential.”

Professional Communication and Team Collaboration, AHRQ1

Source: Awad, S et. al., “Bridging the Communication Gap in the Operating Room with Medical 1) Agency for Healthcare Research and Quality (US). Team Training”, American Journal of Surgery, 190 (2005); Advisory Board interviews and analysis.

With a much larger care team, effective Poor Coordination Hinders Performance complex patient care requires collaborative working relationships. The doctor-nurse relationship is one of Link Between Doctor-Nurse Collaboration and Patient Outcomes the most critical clinical relationships n=3 Intensive Care Units on the care team to get right. The 1.0 extent to which doctors and nurses collaborate on care has a very real Risk of negative outcomes 0.9 impact on the quality of care patients decreases as doctor-nurse receive. collaboration increases 0.8 Unfortunately, all too often doctors and nurses are neither collaborating nor Ratio of Negative communicating effectively. 0.7 Outcome to Predicted Mortality 0.6

0.5

0.4 01234 Collaboration Score

Doctors and Nurses Failing to Communicate Effectively

Percent of time nurses Percent of doctors and Percent of cases in 87% and doctors are in 50% nurses that have 30% which top three patient partial or no discussed patient with priorities do not agreement about each other by 2:30 p.m. overlap between doctor patient priorities and nurse

Source: Baggs J, et al., “Association Between Nurse-Physician Collaboration and Patient Outcomes in Three Intensive Care Units”, Critical Care Medicine, 1999, 27(9):1991-1998; Evanoff B, et al., “Can We Talk? Priorities for Patient Care Differed Among Health Care Providers”, Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings), Rockville, MD: Agency for Healthcare Research and Quality, February 2005; Advisory Board interviews and analysis.

Increasingly, technology is seen as a Still Need Face-to-Face Collaboration for Effective, Efficient Care solution for today’s communication challenges. The information technology investments being made by many today will surely help to curb mistakes and expedite information sharing. EMRs May Hinder Communication But, technology is not a cure-all. The • Difficult to share information across need for human interactions in decision Australian Doctors different EMR systems making is not going away, especially Who Reported 83% 1 given the complex nature of caring for Actively Using EMRs • Time consuming to consolidate multimorbid patients. Rather than rely information from multiple providers solely on the hopes of a technology fix, • Challenging to engage patients while hospitals must ensure their clinicians completing EMR templates are equipped to communicate • Challenging to resolve conflicting or effectively with one another and contradictory patient information or collaborate as members of a team. treatment plans

Interpersonal Communication Still Central to Care Quality "The best way to ensure good coordination of care is for two physicians to speak with each other directly. You can't approach any technology solution, in as complex and risky a work environment as the practice of medicine, and have it be a substitute for appropriate human interactions."

Chief Medical Officer, US, “Post-EHR Changes in Communication”

Sources: Jones S, et al., “Guide to Reducing Unintended Consequences of Electronic Health Records”, Agency for Healthcare Research and Quality, https://www.healthit.gov.; “Electronic Health Records Result in Reduced Medical Errors for Australian Doctors, Accenture Survey Finds”, Accenture, https://newsroom.accenture.com.; Friedberg M, et al., “Factors Affecting Physician Professional Satisfaction and Their 1) Electronic Medical Records Implications for Patient Care, Health Systems, and Health Policy”, RAND, http://www.rand.org; Advisory Board interviews and analysis.

There are two primary reasons why poor communication continues to be a problem for hospital teams: collaboration is not prioritised, and clinicians lack communication skills. Key Barriers to Effective Interdisciplinary Teamwork

Until very recently, clinical training did not put a premium on working effectively as a team. Many clinicians are therefore unaware of or don’t see Collaboration Not Prioritised Communication Skills Lacking the need for extensive collaboration to Focus on individual-based care and Staff report not knowing how to work provide optimal patient care. For clinical training does not emphasise most effectively as a team, delayed decades, the prevailing model of shared decision making information sharing medicine promoted self-sufficiency.

Now that care teams are much larger, that model cannot be sustained. There is now a clear need for optimal team communication and collaboration. But, many clinicians still have not fully We Need Pit Crews, Not Cowboys developed the skills necessary to work “In 1970, it took two full-time clinicians–a nurse’s time and a little bit of doctor’s time–to treat a patient. By most effectively in a large team the end of the 20th century, it had become more than 15 clinicians for the same typical hospital patient environment. (specialist, physical therapists, and nurses). We are all specialists now…everyone just has a piece of the care. But holding on to the structure that we built around the daring independence, self-sufficiency of each of those people, has become a disaster. We have trained, hired, and rewarded people to be cowboys, but it is pit crews that we need.” Atul Gawande, Surgeon and Journalist

Source: Atul Gawande, “How Do We Heal Medicine?”, TED, March 2012, http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine; Advisory Board interviews and analysis.

Ultimately, poor communication and Theatre Task Force Surfaces Poor Team Collaboration as Key Driver collaboration is both an efficiency and a quality concern.

At Emory Healthcare, a health system in the US, executives were dissatisfied with the quality of care within the Low Quality Scores Reflected in organisation. Their two major hospitals Emory’s 2006 UHC1 Rankings were ranked in the bottom half of the Poor Quality Outcomes Rooted in quality rankings from University Ineffective Teamwork HealthSystem Consortium, a benchmarking organisation serving US “When our chair of surgery was charged academic medical centres. with improving specific metrics in the OR 1. around patient flow, patient safety, and Many of the quality concerns centred 2. clinical quality, he put a task force on Emory’s operating theatres, so 3. together and they reported that one of the executives put together a task force to 4. things that keeps getting in the way is that determine the root cause of quality ... we don't know how to work well with each misses. The team’s findings were a 63. Emory University Hospital other, we don't know how to function surprise: quality concerns were … together as a team.” overwhelmingly rooted in how the team 73. Emory University Hospital Midtown Hal Jones, worked together, not necessarily in Assistant Dean, Emory Medical School, their clinical competencies. and Director of Culture, Emory Medicine

Source: Grant S, “Transforming Care Through Interprofessional Practice and Teamwork”, October 9, 2012, ANCC Magnet Preconference; Emory 1) University HealthSystem Consortium. Healthcare, Georgia, US; Advisory Board interviews and analysis.

The same task force that identified Ward-Level Pledge Commits Staff to Improving Teamwork poor teamwork as a primary quality concern in the operating theatres was tasked with suggesting solutions. Establishing a Shared Commitment to Emory’s Signed Teamwork in Emory’s Surgical Department Communication Agreement Consultations with clinicians and patients quickly showed that many Engaged operating theatre doctors, nurses, operating theatre staff had not medical students, and patient advisors in considered how their actions affected discussion about behaviour and teamwork other members of the team, nor had they been trained in what constituted acceptable team behaviour. Designed a pledge that defines ways To address this, the task force team members will treat each other; developed The Pledge with the help of includes commitment to hold each other accountable for behaviour operating theatre team members. The Pledge outlines a shared code of conduct, defining how team members will treat each other and hold each Pledge signed by full theatre team; has See the Signed Pledge other accountable for behaviour. been incorporated into strategic plan Example in the Templates and and rolled out across entire organisation Tools section (page 122). Once all staff have agreed on the components of The Pledge, they sign it as a visible demonstration of their commitment to adhering to a higher standard of teamwork and team-based Case in Brief: Emory Healthcare care. • Five-hospital system in Atlanta, Georgia, US Because the rollout of The Pledge in • Poor interdisciplinary teamwork identified as cause of quality and safety issues in operating theatres; the operating theatres was so task force led to development of communication and collaboration pledge successful, Emory’s executive team • The Pledge defines ways team members should and should not behave; includes commitment to hold sought to use The Pledge organisation- each other accountable for communication wide to improve quality. • Emory incorporated agreement into strategic plan and rolled out across system in 2011; accompanied by staff training on adherence and accountability

Source: Grant S, “Transforming Care Through Interprofessional Practice and Teamwork”, October 9, 2012, ANCC Magnet Preconference; Emory Healthcare, Georgia, US; Advisory Board interviews and analysis.

At the same time that the operating Building Support for a Shared Vision of Collaboration theatre task force was developing The Pledge, Emory’s executive team was in the process of updating the organisation’s strategic plan and vision. Emory’s Transformation Journey Executives knew that to improve quality, the organisation would need to develop a culture of quality care. They Implemented System-Wide wanted to emphasise team-based care Culture Change as a central pillar of that work, and saw The Pledge as an opportunity to firmly cement team-based care in the Created Defined Gathered Identified Pledge Vision Support Gaps organisation.

Once the board incorporated The • Surgical task • Sought to • Board passed • Created Care • Recruitment Pledge into their strategic planning, force drafted strategically link resolution to Transformation • Performance they created committees to identify any behavioural culture and embrace Pledge Committees to evaluations gaps between the organisation’s agreement quality across identify gaps current reality and the team-based care organisation between vision • Staff and medical • Care team • Identified student training vision they set out. These Care members collaborative • Executives for culture and Transformation Committees uncovered signed Pledge decision making incorporated current reality • Strategic gaps by facilitating focus groups with planning • Theatre as central to collaboration • Facilitated focus Emory staff to discuss culture and improved Emory’s culture tactics into groups to discuss team-based care. strategic plan culture with staff clinical results Based on the operating theatre’s experience with The Pledge and these focus groups, Emory rolled out system- wide changes across recruitment, performance evaluations, staff and student training, and strategic planning.

Source: Emory Healthcare, Georgia, US; Advisory Board interviews and analysis.

Emory ensured that the renewed commitment to team-based care applied to everyone in the organisation.

When recruiting, Emory has all prospective applicants watch a video about the organisation’s culture before Emory’s Strategies to Embed Teamwork Across All Levels of the Organisation applying. They have also introduced questions about teamwork and organisational culture into interviews for department chairs. Both steps help Recruitment Performance Goals Incident Resolution ensure new hires will be committed to collaborative care. • Department chair interviews • Executive team members select • Incident reporting system includes include questions about a Pledge-related goal for category for behavioural incidents For existing employees, Emory organisational culture, teamwork performance evaluation • CMO1, COO2, Assistant Dean for introduced team-based care • Prospective applicants required to • Hospital mirrors executive Culture, and department chairs performance goals. After executives watch video about Emory’s commitment model, has all staff involved in addressing behaviour tied their own performance to The culture before applying choose annual performance inconsistent with Pledge Pledge, one hospital in the Emory goal tied to Pledge standards health system decided to have all staff choose an annual performance goal tied to Pledge standards. This tactic worked so well within the first year that they felt they did not have to do it again the following year—clinicians had The Currency of Leadership Is Attention made a major commitment to team- “If we say teamwork is important but we're not paying attention and responding—in very intentional ways— based care. to how team members interact with each other, then what we say loses power. We need to have tactics that show we're paying attention to teamwork and that there are consequences to not paying attention to Finally, Emory recognised that they that if you're a manager or a staff member.” needed to have a method for resolving incidents in which staff acted counter to Hal Jones, Assistant Dean, Emory Medical School, and Director of Culture, Emory Medicine team-based behaviour. They created a new category in their incident reporting system for these events and showed executive support through the involvement of the CMO1, COO2, or 1) Chief Medical Officer. Dean for Culture in incident resolution. 2) Chief Operations Officer. Source: Emory Healthcare, Georgia, US; Advisory Board interviews and analysis.

Emory’s institution-wide commitment to Focused Training to Instil Accountability Beyond the Pledge team-based care is an accomplishment in and of itself. But, executives realised that if they wanted team-based care to truly become embedded in the Actions Emory Took to Reinforce organisation, then staff would need Collaboration in Daily Practice opportunities to hone team-based care Teaching Interpersonal Accountability skills. “Elephant in the Room” Exercise Participants name unspoken barriers to holding “It's not just about publishing and Emory developed a seminar to teach each other accountable for behaviours distributing the behavioural expectations. staff about The Pledge and how the Equally important is systematically organisation expected them to work teaching a critical skill set that does not with each other. To reinforce what come naturally to most people—teaching clinicians learn in the seminar, the “Cup of Coffee” Conversation Role Play them how to confront and, in a caring, organisation uses two interactive, Participants practice having difficult supportive, non-hostile way, talk with their team-based exercises: the “Elephant in conversations with colleagues over coffee team member when he or she exhibits the Room” exercise and the “Cup of ‘non-Pledge-like’ behaviours. Hierarchical accountability is clearly important. By far, Coffee” conversation role play. These though, the most meaningful and enduring exercises help equip staff with the skills Pledge Partners cultural change occurs through collective necessary to deliver constructive Doctors and staff who have participated in accountability—when individuals begin to feedback and hold each other previous training sessions help lead sessions hold each other accountable to the accountable for proper teamwork and serve as coaches after training behaviours on The Pledge, and engage behaviours. each other in those conversations.” Finally, Emory has also created a Hal Jones, See the “Cup of Coffee” conversation guide in Assistant Dean, Emory Medical School, Pledge Partner role that uses volunteer the Templates and Tools section (page 123). and Director of Culture, Emory Medicine clinicians to give others support in adhering to The Pledge.

Source: Emory Healthcare, Georgia, US; Advisory Board interviews and analysis.

Emory’s multiyear journey and Effective Interprofessional Communication Improves Care Outcomes commitment to embedding team-based care in all that they do has produced tremendous benefits. 1 The organisation’s hospitals have not Emory’s 2012 UHC Rankings only risen to the top tier of their Emory University Hospital Emory University Hospital Midtown rankings, they have also dramatically #2 #6 improved their quality of care.

Results of Interprofessional Collaboration Agreement Piloted in 2009

Mortality Index Overall Core Measure2 Compliance Rolling 12-Month Average 17% increase in compliance 0.8 37.5% decrease in mortality index 96% 82% 0.5

2009 2012 2009 2012

1) University HealthSystem Consortium. 2) Core measures are set measures in the US that track a variety of evidence-based Source: Grant S, “Transforming Care Through Interprofessional Practice and Teamwork”, October 9, 2012, ANCC standards of care and are directly tied to payment incentives. Magnet Preconference; Emory Healthcare, Georgia, US; Advisory Board interviews and analysis.

With very poor communication and little collaboration amongst emergency department clinicians, Inselspital Bern in Switzerland faced a very similar Key Challenges Inspire a Change in situation to Emory. ED Staff Training at Bern Near Misses in Patient Care A lack of communication both within “We had situations such as a nurse the clinical team and between seeing the patient’s pulse changing clinicians and the patient and their Breakdowns in Communication and not saying anything. The nurse family was directly impacting the Doctors and nurses were not working said, ‘Well, you’re the doctor, why quality and speed of patient care. together collaboratively should I say something?’ and I said, Critically, non-medical staff felt ‘Well, I didn’t see the monitor. You discouraged from pointing out missteps looked at it—why didn’t you say in treatment or process steps. something?’ So this is something Non-medical Staff Feel Disempowered we really tried to improve.” Nurses did not feel they could speak up about Monika Brodmann Maeder, MD, MMEd treatment processes and potential errors Department of Emergency Medicine, Head of Education, Inselspital Universitätsspital Bern

Poor Communication with Patient and Family Staff did not seek input on care from patients and family

Case in Brief: Inselspital Universitätsspital Bern • 1,100-bed university hospital located in Bern, Switzerland • Emergency department recognised that staff lacked skills to effectively make team-based care decisions, creating gaps in quality and efficiency of care • Simulation training exposes problems in interprofessional collaboration and teaches individuals to work better as a team, improving care quality

Source: Inselspital Universitätsspital Bern, Bern, Switzerland; Advisory Board interviews and analysis.

Bern decided to use an unorthodox Training Must Be Interactive, Highlight Collaborative Breakdowns approach to improve team communication and collaboration. The emergency department team is now required to do an annual team Simulation Staff Training Process at Bern simulation training with an actor as patient, all of which is videotaped.

The recorded simulation training sets Staff Attend Staff Participate Debrief Yields this tactic apart from many education Theory Lesson in Simulation Improvement efforts at other organisations. While many hospitals provide interdisciplinary ED nurses and doctors attend Care teams participate in Staff members meet to watch training opportunities, these lesson to review concepts and videotaped treatment simulation treatment video, discuss what they opportunities are often interdisciplinary treatment plans for the condition with actors trained as patients could improve, and hear actors’ or patient group in focus during or high-tech patient simulators feedback, focusing on better in name only, with doctors and nurses training process communication and collaboration simply undergoing training in the same lecture hall.

The simulation forces the team to act with the actor as they would with any other patient, exposing any Feedback Reveals Tension, Inefficiencies breakdowns in collaboration. Once “(The actress) realised that sometimes the goals of the patient and the nurses and doctors are not the finished, the team debriefs with the same. And she realised quite easily that there was tension between the team when there was a difference actor by watching the video, discussing of opinion on what was best for the patient. In this simulation, it was the first time the team had feedback what could be improved to better from a patient.” communicate and collaborate. Monika Brodmann Maeder, MD, MMEd Department of Emergency Medicine, Head of Education, Inselspital Universitätsspital Bern

Source: Inselspital Universitätsspital Bern, Bern, Switzerland; Advisory Board interviews and analysis.

Clinicians can often see ED Staff at Bern Improve Cooperation, Awareness of Patient Needs communication training as “soft” and perhaps unnecessary. Bern’s simulation training continues to be a critical component of their work to embed team-based care within their organisation because it enables Key Benefits of Bern’s Team Training clinicians to see their own behaviour— and their strengths and weaknesses— reflected back to them through video.

They attribute more balanced Greater Efficiency, Higher- Staff More Responsive to Improved Staff communication between medical and Quality Patient Care Patient Needs Communication nursing staff as well as several process Training identifies improvement Communication with patients Staff thinking shifted to team- changes in the emergency department areas in care, leading to and families improved, based care; speak up when to this training regimen. changes in current processes incorporating actor feedback teammates communicate poorly

Training Program Creates Culture of Communication “The nurses are no longer so reluctant to talk about critical things with the doctors. They can go up to one and say there has been a problem with communication—this is quite new for them. They were afraid to give feedback to doctors before, but now it is possible.” Monika Brodmann Maeder, MD, MMEd Department of Emergency Medicine, Head of Education, Inselspital Universitätsspital Bern

Source: Inselspital Universitätsspital Bern, Bern, Switzerland; Advisory Board interviews and analysis.

Leaders at Hospital Israelita Albert Nurse Feedback at Albert Einstein a Key Part of Doctor Evaluations Einstein in Brazil recognised that doctor commitment to teamwork was one of the biggest barriers to a strong The Individual Benefits of Teamwork doctor-nurse relationship and broader team-based decision making.

To shift doctor culture, leaders decided to include a collaboration component in Giving Nurses a Voice Making the Input Influential A Reason to Listen a scorecard used to measure doctor Nurses submit a Nursing feedback affects Top doctors incentivised via: five-question overall yearly doctor performance. For this section, nurses • More patient referrals submit an evaluation of how well each communication and evaluation and performance • Institutional recognition doctor communicates and collaborates teamwork evaluation rating at Albert Einstein with the interprofessional team. form for each doctor • Inclusion in strategy committees • Free meals at hospital restaurant This evaluation is an important part of the performance scores doctors • Free access to gym, better parking receive, impacting the number of benefits they have access to while working at the hospital. Making Evaluations a Core Value “Physicians are tiered in four categories: AAA (c. 300 physicians), A (c. 900), B (c. 2,000) and C (c. 4,300). They all have nice benefits for being part of our staff, but for the sake of meritocracy, benefits, privileges, and recognitions get better as they climb up the ladder from C to AAA.” Miguel Cendoroglo Neto, CMO, Hospital Israelita Albert Einstein

Case in Brief: Hospital Israelita Albert Einstein • 1,220-bed private hospital system in São Paulo, Brazil • Hospital leadership created scorecards to evaluate the performance of its doctors and to incentivise them with certain benefits for a better score • Nurse evaluations of doctors a key part of the scores to stress the importance of cooperation with nurses • Results show improved performance of doctors and better nurse scores over time, demonstrating that institutional commitment to culture change yields results

Source: Hospital Israelita Albert Einstein, São Paulo, Brazil; Advisory Board interviews and analysis.

Each doctor is evaluated by multiple Questions Address Communication, Efficiency, and Quality Issues nurses so that the score is not based on just one nurse’s opinion of the doctor.

Nurses are asked to rank doctor performance across a series of five Towards a Fair and Sustainable Model questions that centre around good communication and collaboration.

To reinforce institutional commitment to improving the doctor-nurse Collecting Feedback Sending a Message Supporting Model with Data relationship, the evaluations are done Four to five nurses per Periodic evaluation indicates Analysis of data indicates periodically throughout the year. The doctor ensure evaluations institutional commitment to nurse feedback has positive data gathered from the evaluations is include a range of opinions the model and provides statistical correlation with also compared against other indicators benchmark data doctor performance indicators of doctor performance.

Question 1 2 3 4 5

Doctor X shares information about the care plans of their patients with the interdisciplinary team. Doctor X shares discharge plans with the interdisciplinary team.

When necessary, Doctor X is easily found/contacted.

Doctor X has a cordial relationship with the interdisciplinary team. Doctor X adheres to the Surgical Checklist – Time Out.

Source: Hospital Israelita Albert Einstein, São Paulo, Brazil; Advisory Board interviews and analysis.

Albert Einstein’s decision to tie doctor Evaluations Affect Behaviours, Help Change Culture performance incentives to improving the doctor-nurse relationship has been successful across the board. Improving Scores Over Time The improved scores have been positively correlated with overall doctor 4.2 4.1 Positive Correlations 1 performance scores as well as with 4.0 Observed adherence to the organisation’s 4.0 3.9 3.8 fundamental quality pillars and with 3.8 With doctor tenure doctor tenure. 3.7 3.8 3.6 While the top-performing doctors have 3.7 With overall seen the largest increase in score from 3.6 3.5 doctor score the nurse evaluations, all doctor groups 3.4 3.4 have improved to some extent. With institutional 3.2 3.3 3.3 quality pillars2 3.0 2013 2014 2015 Premium (AAA) Advance (A) Evolution (B) Special (C)

Nurse Feedback Leads to Performance Improvement “The evaluation is given to the physicians in the form of feedback with indicators so that they know how the nurses see them in terms of communication and team play. I attribute the physician improvement in performance to this evaluation. We talk a lot about this at our hospital.”

Miguel Cendoroglo Neto, CMO, Hospital Israelita Albert Einstein

1) Pearson coefficient. 2) The quality pillars are defined as: Loyalty, Quality of Practice, Research and Education, and Social Responsibility. Source: Hospital Israelita Albert Einstein, São Paulo, Brazil; Advisory Board interviews and analysis.

Employ a New Type of Team Leader

Tactic 4: Hospitalists: In-Hospital Generalist Decision Makers Case Study 1: Clínica Alemana, Chile Case Study 2: William Osler Health System, Canada Case Study 3: Saint Francis Hospital and Medical Center, US Case Study 4: The Mount Sinai Hospital, US

While improved communication skills will enhance the quality of information clinicians share, clinicians must also work together to enhance the Care Team Composition at Decision Points in Patient Journey operations of decision making. This is inherently more challenging for complex multimorbid patients. Doctor, Nurse Average For example, an “average” patient, one Patient Patient with just one condition that can be Doctor Discharged treated with a smaller team, will have few decision points in their journey, requiring less coordination. But a complex patient, with multiple conditions and a large care team, will have multiple decision points across Doctor, Nurse, their journey through the hospital. Specialist Doctor, Nurse, Pharmacist Each decision point presents another Doctor opportunity for a mistake or inefficiency as the number of involved clinicians Complex Patient rises and the number of options per Patient Discharged decision increases. Multidisciplinary Team Doctor

! More people involved More options More decision points at each point per decision

Source: Advisory Board interviews and analysis.

No matter where in the world you need hospital care, as a complex patient, the more people involved in your care, the more likely there will be problems with Coordination Problems by Number of Doctors Seen it. For example, one study measured Percentage of Patients Reporting Coordination Problems coordination problems with medical with Medical Records or Test Results records or test results by number of 45% doctors seen—in every country studied, the percentage of patients reporting problems nearly doubles (or more) when more doctors are involved 35% in care. 33% 32% 32%

21% 21%

17% 16% 14%

10%

Australia Canada Netherlands New Zealand United Kingdom United States

One or Two Doctors Four or More Doctors

Source: Schoen C, et al., “In Chronic Condition: Experiences of Patients with Complex Health Care Needs, In Eight Countries, 2008”, Health Affairs, 28, no. 1 (2009); Advisory Board interviews and analysis.

With a much larger care team involved Must Know When Group Decisions Are Necessary in complex patient care, decision speed and quality suffers. Though group decision making is a fact of complex patient care, hospitals must ensure that this process is as efficient and effective as possible. Overcoming the Problems of Inefficient Decision Making…

Hospitals need an effective decision model that reduces unnecessary Input from Cumbersome groups decision when possible and Too Many Clinicians Teamwork Structure improves the efficacy of group decisions when they are necessary.

Organisations can reduce the need for group decisions by employing a new …with the Elements of an Effective Decision Model type of team leader who is equipped to manage complexity with fewer consultations. Employ a New Type of Construct Reliable Group For decisions that still require or greatly Team Leader Decision Processes benefit from broader group input, organisations must optimise decision- making processes that are not Reduce need for group decisions Optimise group decisions when currently fit for use by a large group. with leader best equipped to they are necessary autonomously manage complexity

Source: Advisory Board interviews and analysis.

In the current system, the doctor that Current Decision-Making Model Requiring Input from Multiple Doctors admits a complex patient will likely be a specialist that will be unable to make decisions about the holistic needs of the patient on his or her own.

The admitting doctor will rightly call for Current Communication Flow for Complex Patients consultation from the specialties ! required, but these consults take time, Problems Associated with especially if the consulting specialist Present Model has other, more pressing, Pulmonologist Lack of Availability (Admitting Doctor) responsibilities. From these consults, Specialist in charge has the admitting doctor will often get Deciding whether to discharge patient conflicting responsibilities and conflicting treatment information that is has to wait for other specialist biased by its source. Furthermore, the consults before proceeding with admitting doctor may not get all treatment specialty consults necessary before making a treatment decision, Surgeon Missing Information potentially leaving out critical Cardiologist Specialist in charge may not information. Thinks minor surgery Consulted with surgeon, have specialisation or knowledge is needed; only spoke wants to keep patient required to make the medically The process is thus cumbersome, and to cardiologist for observation appropriate decision rife with opportunities for poor and slow decisions. Neurologist Result Unnecessary LOS1 and risk of Hasn’t had time to consult, deterioration and mistakes but has critical information

1) Length of stay. Source: Advisory Board interviews and analysis.

In the community, a general Missing a Generalist Decision Maker in the Acute Setting practitioner maintains a holistic overview of a patient’s care, understanding how that patient’s conditions interact and reconciling the information delivered from various specialists. Unfortunately, most Gap Between Generalist Coverage in hospitals typically do not have a similar Community Versus Acute Care role designed to comprehensively own Generalist Best Equipped Community Acute Care a patient’s care during their stay. “When a single disease Without a generalist in charge of dominates a patient’s health problems, a specialist may be complex patient care, hospitals are the optimal primary decision suffering from a gap in person-centred Gap in Generalist maker. Most often, a generalist decision-making capability—there is Decision Making General with expertise and experience in often no one person that is skilled to Practitioner caring for complex patients with make the holistic decisions necessary Generalist Care Care Generalist multiple chronic conditions may to effectively treat multimorbid patients. be best equipped to supervise care that requires integrating across all conditions within the context of each patient’s health goals and priorities.” Designing Health Care for Specialist Doctors Specialist Doctors the Most Common Chronic Specialist Care Condition—Multimorbidity

Source: Tinetti M, et al., “Designing Health Care for the Most Common Chronic Condition—Multimorbidity”, JAMA, 2012; Advisory Board interviews and analysis.

Care of multimorbid patients needs to Hospitalists Elevate Generalist Decision Maker to Same Level as Specialists be led by a clinician with broad skills who can understand the patient’s medical and psychosocial conditions as a whole. This hospital-based specialist in generalism has become A New Type of Doctor? known globally as a “hospitalist”. “We anticipate the rapid growth of a new breed of physicians we call ‘hospitalists’—specialists in inpatient medicine—who will be responsible for managing the care of hospitalized patients in the The hospitalist is to the hospital what same way that primary care physicians are responsible for managing the care of outpatients.” the general practitioner is to the Robert Wachter, M.D., and Lee Goldman, M.D., community: they are the primary “The Emerging Role of ‘Hospitalists’ in the American Health Care System” decision makers for patients under The New England Journal of Medicine, 1996 their care and they draw from a broad knowledge base to be the connector among different specialties. Key Characteristics of a Hospitalist Hospitalists are most often part of a Capability and Responsibility Teamwork and Accessibility broader team, drawing support from dedicated nurses and allied health professionals to provide continuous care to their patients.

And, unlike many specialist doctors Full Care Generalist Multidisciplinary Availability to working in-hospital, hospitalists are Ownership Background Support Patients staffed to provide 24/7 coverage for Hospitalists are the Hospitalists usually Hospitalists are supported Hospitalists, easily their patients. This makes hospitalists primary decision trained as specialists in daily by a dedicated team accessible to patients easily accessible to patients and maker and general or internal of nurses and Allied Health and families, are able to families and allows them to make real- responsible doctor medicine; able to serve professionals in order to create and continuously from admission to as a hub between provide comprehensive, reassess care plan time changes to care plans. discharge different specialties round-the-clock care together with patient

Source: Wachter R, Goldman L, “The Emerging Role of ‘Hospitalists’ in the American Health Care System”, NEJM, 1996; Advisory Board interviews and analysis.

Hospitals in Canada and the US have Majority of Hospitalists Come from Already Established Fields already invested heavily in the hospitalist model. The experiences of those organisations are therefore useful for hospitals in other regions to Most Common Hospitalist Backgrounds examine to speed up the pace of Potential Hospitalists Already Available • General Internal Medicine change and avoid potential pitfalls. “Following medical school, hospitalists • General Practice/Family Medicine The first challenge to developing a typically undergo residency training in • General Paediatrics hospitalist programme many general internal medicine, general pediatrics, • Geriatric Medicine organisations will face is how to staff or family practice, but may also receive the programme with hospitalists. Many training in other medical disciplines. Some • Intensive Care Medicine feel a hospitalist programme is a non- hospitalists undergo additional post- • Obstetrics and Gynaecology starter because they have no doctors residency training specifically focused on • Related general or internal already trained for the role. hospital medicine, or acquire other indicators of expertise in the field […]” medicine subspecialties However, developing a hospitalist Definition of a Hospitalist and Hospital programme does not require hiring Medicine, Society of Hospital Medicine, US doctors already trained as hospitalists. In fact, the vast majority of hospitalists practicing in Canada and the US trained in family or internal medicine and then took the role of hospitalist at a 90% 82% later time. of Canadian hospitalists of US hospitalists trained Additionally, smaller rural hospitals trained in family medicine in internal medicine have found success creating an integrated practice in which a highly skilled doctor works in the emergency department or the ICU, but also serves as the organisation’s hospitalist. Rural hospitalists are also often expected to provide additional value services for the hospital, such as serving on staff committees or participating in guideline Source: Soong C, et al., “Characteristics of Hospitalists and Hospitalist Programs in the United States and Canada”, Journal of Clinical Outcomes development, in return for financial Management, 16, no.2 (2009): 69-74, http://turner-white.com/pdf/jcom_feb09_hospitalists.pdf; “Definition of a Hospitalist and Hospital Medicine”, Society of Hospital Medicine, 2009, http://www.hospitalmedicine.org/Web/About_SHM/Industry/Hospital_Medicine_Hospital_Definition.aspx; support. Advisory Board interviews and analysis.

The second challenge typically faced in Resistance to Hospitalists Common Across Health Systems developing a hospitalist programme is overcoming early opposition to the role.

Opposition to hospitalists is a trend Early Opposition in US and Canada Still Not Convinced Globally globally, mirroring early resistance to adopting the role in both Canada and Use of Mandatory Hospitalists Blasted “The hospitalist model is not congruent with the US. ACP1 Internist, US, 1999 our metropolitan sort of models at all. I've always struggled to understand how you But in both the US and Canada, would actually introduce high level generalism growing need for the role helped “The hospitalist movement is not or hospitalism into our proper secondary and organisations overcome early being driven by economics, it's being driven by doctors' tertiary hospitals unless you had some sort of resistance and establish this role as relationship with the specialties themselves." one of the fastest growing specialties. lifestyle preferences.” AAFP2, US, 1998 ED of Medical Services, Australia, 2015

“GPs3 understand the ability and capacity of the Hospitalist Concept: Another community to manage particular complex Dangerous Trend patients, something that the hospital-setting AAFP2, US, 1998 hospitalist is unlikely to have." Chief of Quality, UK, 2015 Tough Negotiations Avert B.C. Hospitalist Walkout “Physicians are not interested. […] Hospitalists The Hospitalist, Canada, 2006 are not well considered in university clinics […] It’s not even a question of money, because people can make very good money doing that job. It’s a question of credibility with peers and colleagues.” Medical Director, Switzerland, 2015

Source: Maguire P, “Use of Mandatory Hospitalists Blasted”, ACP Internist, http://www.acpinternist.org/archives/1999/05/hosps.htm; Brown RG, “Hospitalist Concept: Another Dangerous Trend” Am Fam Physician, 58, no. 2 (1998): 339-342, http://www.aafp.org/afp/1998/0801/p339.html; 1) American College of Physicians. Henry LA, “What the Hospitalist Movement Means to Family Physicians”, Fam Pract Manag, 5, no. 10 (1998): 54-62, 2) American Academy of Family Physicians. http://www.aafp.org/fpm/1998/1100/p54.html; Henkel G, “Tough Negotiations Avert B.C. Hospitalist Walkout”, The Hospitalist, 1 August 2006, 3) General Physicians. http://www.the-hospitalist.org/article/tough-negotiations-avert-b-c-hospitalist-walkout/; Advisory Board interviews and analysis.

In the US, the first market to widely Systemic Pressures Give Birth to a Sustainable Alternative adopt the hospitalist role, the role developed out of necessity.

General practitioners, who had typically come into the hospital to coordinate care for their patients that had been A Combination of Trends Keeps Hospitalists a Priority hospitalised, were heavily shifting their focus to outpatient care. At the same US time, hospital patients continued to be sicker, more complex patients that GPs Shift Focus to Increase in Complexity of Hospitals Incentivised on required coordinated care. These Community-Based Care Inpatient Population Efficient, High-Value Care coinciding trends left hospitals with • Inpatient obligations disrupt • Shift to outpatient care results • Rise in managed care rewards patients that needed a general provision of outpatient care in sicker, more complex efficient, high-value care patients in hospital setting practitioner in-hospital and with few • GP1s able to provide more • Inpatient care involves qualified clinicians to fill that role. accessible care for a large • Complex patients require intensive use of resources; group of patients when multiple specialists, increase emphasises importance of Hospitals began to provide their own available in office need for care coordination rapid decision making and in-hospital generalist care, using decreased LOS hospitalists to fill the gap that had opened in coverage.

Widespread adoption of hospitalists Adjusting to a New Reality was further driven by changes in US “The implementation of the Affordable Care Act and Medicare reforms have tied hospitals’ health policy that shifted hospital focus reimbursements to their ability to improve patient satisfaction, reduce the average length of stay and towards managed care as well as a prevent readmissions—all part of the “value” equation that […] hospitalists can help them reach.” recognition that hospitalists could be instrumental in hospitals’ efforts to “Hospitals Hiring Physicians: Why the Trend Is on the Rise”, reach efficiency and quality targets. Wharton School of Business

Source: Health Economics, “Hospitals Hiring Physicians: Why the Trend Is on the Rise”, Wharton School of Business, Feb. 12, 1) General practitioners. 2014, http://knowledge.wharton.upenn.edu/article/hospitals-hiring-physicians-trend-rise/; Advisory Board interviews and analysis.

As in the US, Canadian adoption of the Different Drivers Produce a Response Similar to That of the US hospitalist model has largely been driven by a decrease in general practitioner inpatient coverage coinciding with an increase in the number of complex hospital patients. Doctor Adjustment to Resource Shortages Drive Model Forward On top of these two shifts, the Canadian acute hospital bed base has CANADA continued to decline, while occupancy rates have risen. Canadian Changes in Doctor Perceptions Growing Numbers of Unattached1 Health System Shift Towards organisations are therefore looking to and Demographics and Complex Patients Efficiency and Cost Reduction hospitalists to help improve hospital • Higher demand for outpatient • Growth in patients without GPs • Decline in number of acute efficiency while maintaining quality of care strains availability of meant hospitals needed to ensure hospital beds, and increase in care. inpatient resources more of their doctors admitted occupancy rates prompt need incoming numbers2 for faster throughput • Better work-life balance and Finally, adoption of the model has been predictability of work pushing • Ageing, increasingly comorbid • Increasing trial evidence of buoyed by younger doctors seeking younger workforce into population harder to manage by hospitalist contribution to quality hospitalist positions, due to the role’s hospitalist positions either community GPs or hospital prompts early adoption of model increased predictability and work-life specialists balance when compared to other medical specialties. The Right Solution to a Complex Problem “…The multitude of physician-, system-, and patient-related drivers, as well as the complex interplay among them, suggests that […] the number of hospital medicine programs across Canada will likely continue to grow.” “Health System Drivers of Hospital Medicine in Canada”, Canadian Family Physician

1) “Unattached” refers to patients who do not have family doctors, or whose family doctors do not have admitting privileges in hospitals. Source: Yousefi V, “Health System Drivers of Hospital Medicine in Canada”, Canadian 2) In Canada, GPs would typically admit their own patients in hospitals, resulting in a coverage gap when patients without GPs would present. Family Physician. 2013 Jul 59 (7): 762-767; Advisory Board interviews and analysis.

Despite early resistance, the hospitalist Hospitalists Now Among Fastest Growing Specialties in US, Canada role continues to grow in prevalence. In the US and Canada, hospitalists are one of the fastest growing specialties, with a huge surge in doctors employed in the role. Estimated Number of Hospitalists On the Road to Change In other markets as well, organisations are beginning to see the value of and United States 44,000+ need for the hospitalist role. “We have moved; we have changed our minds on hospitalists. The culture has changed among certain physician communities, because it is a pragmatic approach and we need those people in order to take care of patients. We need physicians, well trained and stable, to take care of patients.” Medical Director, Swiss Hospital

1,000

2000 2014 “I personally think that if you don't appoint a hospitalist, you're negligent. End of story. I don't think there's any alternative. Because a hospitalist by definition is a physician–so they're 100+ Hospitalist groups in Canada specialists (physicians, for me, are specialists). A specialist who basically focuses on general Full-time or part-time medical care of hospitalised patients.” 330+ hospitalists in Ontario Medical Director, Australian public hospital

Source: Cresswell A, “An Eye for the Bigger Picture: It's Time for a Medical Specialist with an Overview of Patients' Needs”, The Australian, http://www.theaustralian.com.au/news/health-science/an-eye-for-the-bigger-picture-its-time-for-a-medical-specialist-with-an-overview-of-patients-needs/story- e6frg8y6-1226059251705; Health Economics, “Hospitals Hiring Physicians: Why the Trend Is on the Rise”, Wharton School of Business, Feb. 12, 2014; White, H, et al., “Defining Hospitalist Physicians Using Clinical Practice Data: A Systems-Level Pilot Study of Ontario Physicians”, Open Medicine, 7 (3), 2013, http://www.openmedicine.ca/article/view/581/516; Smith S, Sivjee K, “Defining Training Needs, Core Competencies and Future Certification for Canadian Hospitalists”, CMAJ, 184 (14), 2012, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470616/; Advisory Board interviews and analysis.

Given the major changes many organisations will have to make to adopt this new model, this chapter includes in-depth coverage of four case studies that each present a critical Key Strategies for Hospitalist Programme Success component of implementing a successful hospitalist programme. Justify the Investment 1 Clínica Alemana, Chile

Align the Programme to Hospital Goals 2 William Osler Health System, Canada

Localise Hospitalist Care 3 Saint Francis Hospital and Medical Center, US

Extend Hospitalist Reach Beyond Medical Units 4 The Mount Sinai Hospital, US

Source: Advisory Board interviews and analysis.

For Clínica Alemana, a hospital in Root Cause Analysis Identifies Hospitalist Opportunity at Clínica Alemana Chile, the development of a hospitalist role came after the executive team tried to get to the true cause of patient crowding in the hospital’s emergency Symptom: 1 department. Patients crowding ED

As the team traced the problem to its root, they realised that bed block in Delayed transfer to general medicine wards was causing inpatient wards overcrowding in the emergency department. But inpatient bed block by Bed block in itself was not solvable without knowing general medicine its root cause.

The team discovered that emergency Longer than 2 department overcrowding could be necessary LOS for complex patients traced all the way to the slow, uncoordinated treatment of complex patients on inpatient wards. The Slow treatment specialists that were the primary decisions decision makers for these patients were not equipped to make decisions Doctors not available; about multimorbidity, nor were they care uncoordinated always available when they were needed for care. Root cause: Specialists not the optimal care providers on general medicine wards

1) Emergency department. 2) Length of Stay. Source: Clínica Alemana de Santiago, Santiago, Chile; Advisory Board interviews and analysis.

Clínica Alemana decided that to fix the Generalists Able to Address Shortcomings of Specialist-Led Model organisation’s broader patient flow challenges, they would need to fix the problems created by specialists owning Key Characteristics of Clínica Alemana’s Hospitalist Model complex patient care.

The executive team determined that the ideal owner of complex patient care would be a hospitalist: a doctor Hospitalists1 in charge of Hospitalist patients Contracts and schedules specialised in caring for the whole all medical decisions co-located to facilitate designed to provide patient that would provide round-the- faster treatment 24/7 coverage clock coverage and collaborate with a broader team to ensure continuity of Traditional, Specialist-Led Model New, Generalist-Led Model care.

But, as a salaried position, the Responsibility Doctor specialising in single condition Doctor specialising in whole patient hospitalist role was a significant commitment from the organisation and Teamwork Not collaborative, no consistent care team Highly collaborative, allowing continuity came as a trade-off to investment elsewhere. Because of this, Clínica Alemana developed a pilot comparing Coverage Uneven, depending on doctor availability 24/7 traditional specialist ownership of care to hospitalist ownership to justify that the investment in the role would truly be worthwhile. Case in Brief: Clínica Alemana • 429-bed private hospital in Santiago, Chile • Hospital leaders realised that complex patients in the general medicine wards were treated too slowly and ineffectively by specialists, causing bed block throughout the entire hospital and clogging the ED • Additionally, clinical leaders saw large variation in the ways different specialist doctors planned and executed the care of complex patients, leading to widely disparate results and inconsistent quality of care • Implemented a hospitalist pilot to standardise care, improve quality, and reduce unnecessary delays. Pilot used clinically comparable patients to allow for direct comparison of results between hospitalist-led patient group and traditional model

1) The hospitalist role at Clinica Alemana is being taken on by internal medicine doctors, who were shifted to the new role and given new expectations and structure. Source: Clínica Alemana de Santiago, Santiago, Chile; Advisory Board interviews and analysis.

The pilot produced compelling data for Hospitalist Model Providing Faster, More Efficient Care using hospitalists to own inpatient care, with a 50% reduction in average length of stay for the patients in the 1 hospitalist-owned cohort compared to Average Length of Stay by DRG Achieving Extra Capacity patients in the traditional cohort. Days 6.9 Although the overall reduction in average length of stay under hospitalist 17.1 care was impressive, it in fact Estimated number of extra beds “created” if all undersells the importance of using a traditional model patients in the target group hospitalist for complex patient care. 3.7 were treated under the hospitalist model

When Clínica Alemana separated out 2.5 1.9 the pilot data by condition and complexity, it became clear that hospitalist ownership of care had an outsized impact on length of stay for Pneumonia with Pneumonia with Return on Investment complex hospital patients. The data to Pertussis Pertussis with “The initial investment was to establish contractual the right for pneumonia with pertussis 2 MCC relationship with the hospitalists, in order to ensure illustrates this point. continuous, optimal, and 24/7 care under specific Traditional Model The executive team at Clínica Alemana action protocols. The justification: it is much cheaper Hospitalist Model to invest in hospitalists than to add more beds.” felt that the role was amply justified, pointing out that, on top of the Bernd Oberpaur, Deputy CMO in Charge of Projects, efficiency gains, investing in Clínica Alemana de Santiago hospitalists was far less expensive than investing in additional hospital capacity.

1) Diagnosis-Related Group. 2) Major complicating or comorbid condition. Source: Clínica Alemana de Santiago, Santiago, Chile; Advisory Board interviews and analysis.

The graph shown here reiterates the Benefits from Hospitalists Greatest for Complex Patients massive benefit of hospitalist-owned care for complex patients. Hospitalist- owned care resulted in reduced length Average Length of Stay Reduction by Complexity of stay for all patients in the pilot Percentage (%) compared to the control group, but the 100% patients with the largest reductions in Benefits of the hospitalist model increase as patient length of stay were those patients that complexity increases were the most complex. 63.0% 54.5% ALOS1 Variation

25.0%

0% Single Single Condition Single Condition Condition with CC 2 with MCC 3

Continuity and Decision Making Key to Success “The hospitalist doesn’t just have to make decisions, but has to be available to make decisions continuously regarding test results, deterioration of condition, taking temperature, measuring arterial pressure or changes in any other variable; and to work closely with the nurses. There has to be proximity.” Bernd Oberpaur, Deputy CMO in Charge of Projects

1) Average Length of Stay. 2) Complicating or comorbid condition. 3) Major complicating or comorbid condition. Source: Clínica Alemana de Santiago, Santiago, Chile; Advisory Board interviews and analysis.

New roles often take time to optimise; Informal Structure, Misaligned Incentives Undermine Hospitalist Value there is a period of uncertainty that accompanies the development of any role during which both the clinician and Issues with Loose Hospitalist Agreement at William Osler Health System the hospital are trying to understand how to make the role work best. If role responsibilities are not made clear early on, then the role can quickly No set work hours No suitable billing structure become an investment gone bad. Lack of fixed work schedule, Simple FFS1 model may not At William Osler Health System in leading to uneven coverage of provide enough revenue for Ontario, Canada, executives realised shifts and availability of providers hospitalists; complement income that they were not getting full value out with outpatient billing of their hospitalists for this very reason. The hospitalist role had been staffed, Flexible Understanding but the job functions and contract used were suited for independent doctors, not salaried hospitalists.

William Osler identified four major No caps on patient volume No clear performance indicators areas of concern within the existing hospitalist agreement, seen at right. Hospitalists may focus on Income and reviews not tied to numbers to maximise revenue, hospitalist performance; hospitals spending less time with each unable to assess effectiveness to patient and deepening the extant improve quality of care delivery issues of complex patient care

Case in Brief: William Osler Health System • Largest community hospital in Ontario, Canada, serving a population of 1.3 million • Hospitalist programme suffering from uneven performance, low retention rates, and staff burnout • In 2012, leadership created a new hospitalist contract structure with strict patient intake parameters, financial incentives, and performance metrics

1) Fee-for-service. Source: William Osler Health System, Ontario, Canada; Advisory Board interviews and analysis.

William Osler completely overhauled Rules and Expectations Create Incentives for Person-Centred Care their agreement with their hospitalists to address each of the concerns with the programme.

In close consultation with their hospitalists, executives created a William Osler’s New Agreement with Hospitalists contract that would provide incentives to hospitalists for meeting organisation- wide goals influenced by their work. Set Workday 8- to 10-hour fixed workday for all William Osler combined reliable 26 hospitalists on site presence in the hospital, a competitive financial arrangement, clear Guaranteed Income Key Indicators performance standards, and patient- Hospitalist responsible for delivering at least 65% of income through 1 Length of stay volume caps to ensure hospitalists Structured billing; hospital provides set stipend dedicated the time and attention Hospitalist 2 30-day readmission rate Contract necessary to provide each complex Clear Performance Metrics Accurate discharge patient the best possible care. Clearly defined criteria allows 3 summaries within 24 measurement of performance hours of discharge

Capped Patient Volume 4 Patient satisfaction Each hospitalist allowed 17 to 22 5 Predictive discharge patients in order to avoid using patient volume to grow income 6 Bullet round attendance

Source: William Osler Health System, Ontario, Canada; Advisory Board interviews and analysis.

William Osler successfully transformed their hospitalist programme by making the role work for both clinicians and the health system. Key Elements of William Osler’s New Model They invited current hospitalists to co- write the agreement, ensuring they had buy-in from the group.

William Osler used a combination of Joint Effort Logistical Support financial models to make working “in- Financial Incentives Structural Boundaries hospital only” a competitive alternative Collaborative agreement Comprehensive support Ensure a combination of Fixed work schedules to the independent doctor payment written by both sides in from multidisciplinary order to ensure buy-in fee-for-service and teams, allied health, and caps on patient model prevalent in Ontario. hospital subsidy to make imaging and radiology volumes to avoid desire working “in-hospital only” departments, etc. to maximise revenue To ensure success and high-quality attractive through sheer volume care, the system fully supported the hospitalists in their work—hospitalists work with a multidisciplinary team and have rapid access to allied health and imaging capacity.

To mitigate burnout, avoid individual The System Is the Solution doctors fighting for patient volumes, “Just bringing these physicians in and paying them the extra money a year will not all of a and promote patient-centred care for sudden decrease your LOS. You have to provide them with support–the nurse practitioners, each patient, hospitalists have fixed dieticians, discharge planners, technology, etc. And you have to take all those people and shifts and caps on the number of give them the tools and teach them what is the best way to decrease even a few hours of patients on their rosters. each patient’s admission, which leads to, eventually, half a day or a day off the total LOS.” Dr. Naveed Mohammad, Vice President Medical Affairs, William Osler Health System Taken together, these changes created a fundamentally different hospitalist model for William Osler.

Source: William Osler Health System, Ontario, Canada; Advisory Board interviews and analysis.

William Osler acknowledges that employing hospitalists is a considerable investment. However, the coverage their hospitalists now provide Hospital-Wide Average Length of Stay Reduction During Test Period1 is directly leading to hospital-wide Real Effects on the System reductions in length of stay, fewer Days readmissions, and fewer patient “What you gain in cutting down your complications, making the case for LOS, in 30-day readmissions, and in the continuing the programme. decreased number of complications you 4.77 otherwise have when a physician only 4.68 comes in for 15 minutes or an hour a day to see 10 patients, makes up in many ways more than the money you might be spending on those physicians. Each day in our hospital means another 2,000 dollars on the system and a patient sitting in our ED probably not getting the care they need to get in an inpatient unit…it’s a real trickle-down effect.”

Before Implementation After Implementation Dr. Naveed Mohammad, Vice President Medical Affairs, William Osler Health System

1) Data measured on the basis of average LOS for the same four-month periods before (December 2013-March 2014) and after (December 2014-March 2015) implementation. Source: William Osler Health System, Ontario; Canada; Advisory Board interviews and analysis.

While hospitalist programmes are Physical Distance a Barrier to Hospitalist Effectiveness created to solve the challenges posed by specialist ownership of care, they Travel Time Has Unintended Consequences can sometimes fall prey to those same ! challenges. 60-90 min At Saint Francis Hospital and Medical Average time per day Center in the US, the hospitalist More internal handoffs, hospitalists spent physically resulting in 2-4 programme was well established, but moving between wards at hospitalists per patient not running as effectively as hoped. Saint Francis within a 5-day stay Though the hospitalists were supposed to be providing improved coverage over that provided by often unavailable Growing staff specialists, they were frequently unable complaints about “A hospitalist put a hospitalist availability to do so. pedometer on her feet, and and accessibility Because hospital beds were a scarce she clocked an average of 4-4.5 miles a day. She was good, hospitalist patients were typically always moving. It was hard admitted to the first beds that were Readmission rates to get a hold of the rising to 16%-17% available. This spaced patients across hospitalists even though multiple wards and significantly cut into they were in the hospital.” programme efficiency and quality as Surendra Khera, CMO, Decreasing overall hospitalists had to spend significant Saint Francis Hospital value of programme, time moving from ward to ward to see and Medical Center increasing costs patients.

The overall value of the hospitalist programme was decreasing while Case in Brief: Saint Francis Hospital and Medical Center costs continued to rise, prompting • 550-bed private hospital in Connecticut, US executives to rethink how care should be organised. • Started a six-month pilot with willing hospitalists working solely on a single unit for complex patients, aiming to concentrate care and improve efficiency • Changed hospitalist work schedules to include increased unit coverage and deepen care delivery through daily interdisciplinary rounds involving patients and family • Saw significant decreases in length of stay and readmissions, as well as universal staff approval

Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

Saint Francis decided to overhaul how Model Change Results in Complete Unit Makeover hospitalists worked at the organisation, starting with where they provided patient care. Rather than caring for patients spread out across the hospital, hospitalists now care for patients on single units. The Unit-Based Hospitalist Model ! The Unit Realising that staffing a single unit 1 Different Care Delivery could lead to boredom or burnout, the Hospitalists dedicated to most with Same Resources complex unit programme assigns a hospitalist to an No Additional • 30-bed, complex patient unit (stroke or 8-hour shift in the unit for a month at a medium-to-high LACE score) Financial Resources time. Two other hospitalists are Invested assigned 12-hour shifts working in and • Piloted for 6 months with hospitalists willing to try the new approach • No new staff out of the unit for a week at a time. • No added monetary The Staff The restructured programme gives incentives Fixed model for constant care delivery hospitalists the ability to focus more 2 • One 8-hour shift hospitalist assigned to unit • No added time completely on providing excellent for a month requirements patient care, including participation in • Two 12-hour shift hospitalists assigned to New Structure multidisciplinary rounds with the unit- “float” in and out of unit each week based team, the patient, and their Drives Changes family. • Ease of collaboration The Process Importantly, Saint Francis did not need Increased depth of service • Increased to use any additional resources to accessibility 3 • Hospitalists focus complete time and attention change their hospitalist model of care. on patients of a single unit • Improved • Required daily multidisciplinary rounds with accountability team, patient, and family

Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

Saint Francis chose to pilot their Success Makes the Case for a Hospital-Wide Change dramatic change in how hospitalists provide care to determine whether localising would improve both efficiency and quality.

The pilot unit’s results justified further Planned Phases of Hospital Rollout Pilot Unit’s Results rollout of the model. In fact, the entire hospital will soon adopt the localised 1 successful model of care that Saint Francis now pilot unit 22% uses with its hospitalist programme. 3 more units currently DecreaseD iin 30-day30 d transitioning to model readmission rates

Entire hospital to adopt by end of 2015 10%

Unit LOS reductireduction

Beyond the Numbers “At the end of the six months the hospitalists said that they honestly felt that if that was the model of care, then they would never think of leaving the hospitalist practice. The nurses reported 100% satisfaction with the process and recommended that every single unit in the hospital be converted to a localised clinical microsystem. The model was received extremely well.” Surendra Khera, CMO, Saint Francis Hospital and Medical Center

Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

It’s important to note, however, that Addressing Initial Concerns Through Experience, Evidence creating a unit-based hospitalist programme is not without its challenges. At Saint Francis, the team identified three challenges that bred initial resistance with many of their hospitalists. Common Challenges with Unit-Based Hospitalists

Through the pilot, Saint Francis was Challenge Solution able to show to resistant hospitalists A New Way of Thinking that unit-based staffing could actually Improved efficiency “As the COO, I faced three major address their concerns. Saint Francis Perceived to be more and work environment work for hospitalists challenges with our hospitalist relied on several hospitalists willing to significantly reduced stress and practice: allocating resources to the try the new model to prove its worth, workload among hospitalists hospitalist group that matches the reinforcing the importance of identifying complexity of the patients they take champions of a major shift early on in care of rather than just the number the process. of patients seen; improving overall Rotated hospitalists quality of care, care coordination Lack of variety in types between wards every 3 and decreasing handoffs; and of patients seen months to maintain ability improving nursing and physician to treat variety of patients retention. Complexity-driven localised hospitalist units helped overcome all three of those. It was Reduced delays in transfers hitting three birds with one stone.” Slower inpatient to inpatient wards paid off in admission process John Rodis, MD, EVP, COO, reduced overall LOS and Saint Francis Hospital readmissions rates and Medical Center

Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

More than just an improvement in Units at Saint Francis Organised Around Complexity1, Not Disease hospitalist programme effectiveness, Saint Francis’ shift to unit-based care represents a major change in how 3 hospital care is provided to complex The Standard, Condition-Based Model Saint Francis’ Complexity-Based Units patients. Patient with three diseases Patient with three diseases goes to Rather than base units on disease can only go to a unit high-complexity unit equipped and groups, Saint Francis opted to base dedicated to one of them staffed to treat all conditions units on rising levels of patient complexity, using a readmission risk assessment to place patients. Pulmonology Unit This reorganisation more closely reflects the reality of the hospital’s patients. Now a patient with multiple Gastroenterology Unit Complex Patient Unit conditions can go to a single unit staffed to effectively provide them care, rather than going to a unit for only one Cardiac Unit of their conditions that may not have • Multimorbid patient eligible for three separate • Comorbid patient assigned to unit based the resources to treat the others. units, but assigned to one based on condition on complexity, not condition As complex patients continue to grow • Patient not truly “geolocated2”: unit may not • Hospitalist-led teams on units in number and as a proportion of total have the resources needed to treat all three “specialising in complexity”, staffed to hospital patients, organising care conditions and needs to collaborate with respond to all types of exacerbations and around complexity, not disease, may others, creating delays able to work across disciplines become the best way to scale resources to these patients’ needs.

1) Saint Francis uses the Ontario-developed LACE index score in order to determine the complexity needs of each unit. 2) Geolocation refers to the process of assigning a hospitalist to a single ward and having them take care of the vast majority of the patients on that ward. 3) The new complexity-based model is being used in all inpatient general medicine wards at Saint Francis, except a few units with highly specialised types of patients, such as oncology, heart failure, etc. Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

Centring units around complexity rather than disease has an added benefit of allowing the hospital to better scale resources to meet patient needs.

Rather than having a ward with a mix of complexity that therefore needs all The beauty of the complexity model is that you can levels of staff and resources, the hospital can now dedicate the most resource yourself accordingly. In a low-complexity intensive resources to the patients that unit, you don’t need residents or PAs1 there, a truly need them and scale down single hospitalist with good case management and resources for less complex patients. nurses can be just enough to take care of patients.

But in a unit where the readmission risk is around 35%-40%, with very sick patients, you have to fill it with nurses, with APRNs2 and PAs […] You resource the high-end unit more, so eventually all your outcomes look better compared to when you have mixed complexity on all units. For us, it’s a resource issue and it works better.”

Surendra Khera, CMO, Saint Francis Hospital and Medical Center

1) Physician Assistants. 2) Advanced Practice Registered Nurses – highly trained nurses in the US who are trained to assess, diagnose, and manage patient problems, including order tests and prescribe medications. Source: Saint Francis Hospital and Medical Center, CT, US; Advisory Board interviews and analysis.

Many organisations recognise a need Focusing on High-Risk Patients Most Impactful for medical expertise for surgery patients and have extended the hospitalist’s purview to include helping manage these patients.

Comanagement of surgical patients Annals of Internal Medicine JAMA Internal Medicine Orthopedics refers to patient care in which a Medical and surgical Comanagement of Hospitalist-orthopedic medical specialist “daily assesses comanagement after surgical patients comanagement of high- acute issues, addresses medical elective hip and between risk patients undergoing comorbidities, communicates with knee arthroplasty neurosurgeons lower extremity surgeons, and facilitates patient care and hospitalists reconstruction surgery transition from the acute care hospital Reduced the incidence of Reduced costs, but did not Reduced observed-to- setting to the community setting”. minor complications but impact readmission rates, expected length of stay, but did not reduce major length of stay, or mortality did not reduce cost of care While hospitalist medical complications or mortality comanagement results overall are somewhat mixed, with some studies indicating medical comanagement improves quality metrics and others showing limited impact, more recent research suggests that medical comanagement may be most valuable when used only for high-risk patients Focusing on the High-Risk Patients with multiple comorbidities who need “Recent studies suggest that the benefits of medical comanagement may be limited greater care coordination overall. to high-risk surgical patients with complex medical or care coordination issues.” Eric Siegal, MD “A Structured Approach to Medical Comanagment of Surgical Patients”

Source: Sharma G, et al., “Comanagement of Hospitalized Surgical Patients by Medicine Physicians in the United States”, Archives of Internal Medicine, 170 , no. 4, 363-368, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843086/; Huddleston JM, et al., “Medical and Surgical Comanagement After Elective Hip and Knee Arthroplasty: A Randomized, Controlled Trial”, Annals of Internal Medicine, 141, no. 1 (2004), 28-38; Auerbach, AD, et al., “Comanagement of Surgical Patients Between Neurosurgeons and Hospitalists”, JAMA Internal Medicine, 170, no. 22, http://archinte.jamanetwork.com/article.aspx?articleid=776455; Pinzur MS, et al., “Hospitalist-Orthopedic Co-Management of High-Risk Patients Undergoing Lower Extremity Reconstruction Surgery”, Orthopedics, 32, no. 7; Siegal E, “A Structured Approach to Medical Comanagement of Surgical Patients”, Italian Journal of Medicine, 6 (2012), 347-351, http://www.italjmed.org/index.php/ijm/article/view/itjm.2012.347; Advisory Board interviews and analysis.

Initially, vascular surgeons at The Overuse of Hospitalists for Medical Consultation at Mount Sinai Mount Sinai Hospital in the US were requesting medical consults for most cases, regardless of patient complexity. Hospitalists provided a pre- operation note for all patients, even when this was not necessarily a high- Surgeons Not Maximising Hospitalist Expertise value service from the hospital’s perspective. Case in Brief: The Mount z With hospitalists already stretched thin, Sinai Hospital the hospitalist leader wanted to adjust the comanagement agreement to • 1,171-bed academic medical Surgeons request Hospitalists write pre- target patients for whom hospitalist center in New York, US; all hospitalist consult for op notes, even for support would be most valuable. hospitalists are employed nearly every case low- and medium- acuity patients Mount Sinai thus developed a more • In January 2013, initiated medical comanagement targeted medical comanagement agreements for highest-acuity programme for vascular surgical patients, beginning with patients, improving outcomes by vascular patients targeting hospitalist support for the z most complex patients. • Hospitalist and vascular surgeon champions together developed agreement with Hospitalists stretched Only added value is clearly delineated thin and lack proper surgeon convenience; responsibilities bandwidth to target hospitalists feel • Comanagement agreement high-acuity patients frustrated, underutilised resulted in decreased readmissions rate and mortality

Source: The Mount Sinai Hospital, NY, US; Advisory Board interviews and analysis.

Mount Sinai used a four-step approach Four-Step Approach Creates High-Value Medical Comanagement Agreements to refine their existing medical comanagement agreements.

First, hospitalist leaders identified and clearly defined the patient population that would benefit most from medical Assigned Identify patient population where Responsibility consults. Mortality data indicated high- 1 Doctor hospitalist support is most needed acuity vascular surgery patients should Communicate recommendations for plan Hospitalist be an area of focus. of action and treatment to house staff and other surgery providers Second, they designated a specific Communicate with patients and their Hospitalist hospitalist champion and a vascular Designate hospitalist and surgery champion who would oversee 2 families regarding the medical plan of vascular surgeon champions care, goals, treatments, and options the agreement and ensure both groups adhered to it. Actively manage all medical comorbidities Hospitalist (diabetes, chronic kidney disease, 1 Third, these champions made sure the Champions create highly specific, COPD , anticoagulation, etc.) agreement was very specific, with 3 delineated comanagement Answer calls from the nursing staff when Surgeon clearly delineated roles and agreements with clinical problems arise responsibilities. outcomes in mind Decide on pain management issues Surgeon Finally, after the agreement was implemented, champions monitored Call in subspecialist consultations Hospitalist and quality outcomes compared to quality Compare actual outcomes to goal; surgeon in 4 update comanagement agreement collaboration targets. If quality goals are not as needed achieved, then they adjust the agreement to achieve better outcomes.

Source: The Mount Sinai Hospital, NY, US; FOJP Service Corporation, “FOJP Initiatives: Preoperative Medical Assessment and Co-Management of Surgical Patients”, infocus: The Quarterly Journal for Health Care Practice and Management, 21 1) Chronic Obstructive Pulmonary Disease. (2013), 16-17, http://www.fojp.com/sites/default/files/InFocus_Spring13_0.pdf; Advisory Board interviews and analysis.

Mount Sinai’s focused comanagement Vascular Surgery Results Before and After Comanagement Agreement agreement led to improvements in both risk-adjusted mortality and readmissions rate for vascular surgery patients. The agreement also improved hospitalist satisfaction; their support is Risk-Adjusted Mortality Readmissions Rate now focused more on quality outcomes (Observed : Expected) than managing all requests. 1.02 They continue to improve their 23.1% medical comanagement agreements, even to extend partnerships to other specialties, such as surgical oncology. 0.63 20.2%

Before After Before After

“We started with the vascular surgery patients because they were the sickest, and our results suggest that a highly structured comanagement program targeting these patients can have a substantial impact on patient care.” Andrew Dunn, MD Chief of Hospital Medicine, Mount Sinai Health System

Source: The Mount Sinai Hospital, NY, US; Advisory Board interviews and analysis.

Effective medical comanagement Optimise Hospitalist Role with Effective Medical Comanagement agreements have three consistent characteristics: well-defined target outcomes, explicit roles and processes, and designated hospitalist and specialist champions to ensure adherence. Key Characteristics of Effective Medical Comanagement Agreements To optimise medical comanagement, Questions to Assess Medical organisations should review existing Comanagment Performance at agreements first, ensuring they have Your Organisation targeted outcomes and goals. Then, Well-Defined Target Outcomes consider expanding medical Allows for clear comanagment • Are our hospitalists providing high-value comanagement to other clinical areas goals and determination of success expertise in an effective, targeted way? where there is a significant opportunity – Monitor average acuity of comanaged to improve outcomes. patients, compare to original target criteria Explicit Roles and Process • What are our target goals for hospitalist Clearly defined patient criteria, defined medical comanagement? Are we role for each specialty (who handles reaching them? discharge paperwork, etc.), and clear process when disagreements occur – Identify specific outcomes to monitor success, such as risk-adjusted ALOS1, risk- adjusted mortality, readmissions rate, complications (CAUTI2, VTE3 prophylaxis, Equal Representation infections not present on admission) Designated specialist and hospitalist leaders define a fair, balanced agreement and use influence with their peers to achieve widespread buy-in

1) Average length of stay. 2) Catheter-associated urinary tract infection. 3) Venous thromboembolism. Source: Advisory Board interviews and analysis.

As the case studies provided in this Lessons from the Markets That Have Embraced the Model chapter indicate, hospitalist programmes are without a doubt a significant investment, but they come Elements of High-Performing Hospitalist Programs with a considerable upside if structured correctly. Clear Financial Incentives Unit-Based, Flexible Staffing

The four elements outlined on the right • Shared accountability framework between • Localised units with a number of beds similar or set apart top-tier hospitalist hospitalists and organisation, with clear targets equal to hospitalists’ patient load programmes from their peers. and performance measurement for staff • Hospitalist assigned to units with set shifts on • Billing or salary system created to allow weekdays/nights, rotating on weekends hospitalist income to be comparable to the • Units divided by complexity, allowing hospitalists income of other specialists to rotate assignments every several months to avoid burnout and keep varied patient mix

Performance Scorecards Accessibility, Continuity of Care

Scorecards aligned to utilisation targets1: • Clear hospitalist ownership of care process and • LOS reduction decision-making power • 28-day readmission rates • Dedicated multidisciplinary teams and daily rounds to support hospitalists in each unit • Team satisfaction • Reviews, meetings, and consultations with • Patient satisfaction patients and family at all times

Setting the Right Tone “This model has given us a really strong foundation to build other initiatives on. When we look at where to start certain initiatives, the hospitalist areas are often the areas we start in, and that’s because we feel that the readiness of that whole interprofessional team, the structures they have in place, and the physician engagement all create good foundations for starting other initiatives. So it accelerates performance improvement even more.” Nancy Veloso, Patient Care Director for Medicine, The Scarborough Hospital

1) Sample targets; performance scorecards could include more, depending on organisational values and goals. Source: Advisory Board interviews and analysis.

At The Advisory Board Company, we A Wealth of Advisory Board Research on Hospitalists have studied hospitalists since their inception in the US and have a wealth of resources on the model beyond the case studies included in this book.

All hospitalist resources are available Second Generation Hospitalist The Hospitalist Powered through the Clinical Operations Board Programs (1999) Enterprise (2007) membership and can be found on our Provides practical guidance on how Shares strategies to maintain a cost- website at advisory.com/cob. to improve hospitalist performance, effective hospitalist programme, including including how to hardwire how to overcome obstacles to capture programme management and value and how to leverage hospitalists maximise efficiency across challenging processes

Hospitalist Program Capturing the Full Value of the Financial Fundamentals (2003) Hospitalist Program (2015) Outlines the basics of hospitalist Focuses on ways to improve the programme financial fundamentals effectiveness and ROI of the (including costs, revenue, savings, etc.) hospitalist programme, to demonstrate and provides associated tools its value to executive leaders, and to necessary for a thorough and accurate achieve quality improvement and ROI1 calculation population health goals

All past studies available at advisory.com/cob

1) Return on investment. Source: Advisory Board interviews and analysis.

Construct Reliable Group Decision Processes

Tactic 5: Structured Interdisciplinary Bedside Rounds (SIBR®) Tactic 6: Case Review Conferences

Though multimorbid patient care must Collaborative Decision Making Still Advantageous in Some Scenarios have a clear decision owner that can take on more decisions independently, there will continue to be a need for group decisions. Some decisions are simply better if made through a collaborative decision-making process. Advantages of Encouraging Collaborative Decision Making

When a larger group can come together to discuss a decision, participants can share information Real-Time Insightful and Mechanism for face-to-face, eliminating input delays Information Sharing Productive Debate Enhancing Accountability and allowing for clarifications on the spot.

Bringing the group together can help to • Verbal communication allows • Specialised experts can • Structured meetings ensure challenge thinking and resolve any nuance to be conveyed challenge assumptions information conveyed discrepancies in how care team • Opportunity to ask questions • Disagreements can be accurately and efficiently members approach care. These and clarify information resolved in the moment • Regular meetings ensure conversations can also help to deepen • No delays waiting for input • Collaborative process follow-up on next steps working relationships amongst care encourages relationships • Recognising patterns team members and provide clinicians improves care over time the opportunity to learn for the future.

Recurring meetings encourage clinicians to adhere to next steps—they know that the next steps will be asked about in the following meeting. Having meetings for decisions can also help the care team recognise and address any patterns in care over time.

Source: Advisory Board interviews and analysis.

Despite the reasons why organisations Challenging to Bring Groups Together Without Disrupting Workflow might encourage clinicians to come together to make decisions, it remains challenging to bring together the necessary group.

Very few clinicians have exactly the Fragmented Workflow of Various Care Team Participants same schedule, and schedules differ significantly across care team roles. Any attempt to bring together the full team for collaborative decision making Specialist Surgeries Patient is disruptive to at least one group of in Theatre Rounds clinicians’ workflow. If the group decision-making process isn’t embedded seamlessly into workflow Hospitalist Talking to Patient Docu- and designed to be as efficient as Family Rounds mentation possible, it is likely to be doomed before it even starts. Allied Morning Patient Docu- Outpatient Health Therapy Rounds mentation Clinic

RN Bedside Patient Medication Talking to Patient Handover Rounds Admin Family Education

9:00 a.m. 11:00 a.m. 1:00 p.m. 3:00 p.m. 5:00 p.m.

Time of Day

Source: Advisory Board interviews and analysis.

Hospitals must be strategic about how More Coordination Needed to Get Necessary Team Together they organise decision-making processes to make best use of the power of group decision making.

Just as not all decisions need to be made in a group, not all group Team Composition Dictates Frequency of Group Decisions decisions require the full group, nor do they need to be made daily.

To sustain effective group decisions, organisations should separate day-today care changes from broader Day-to-Day Care Changes Cross-Specialty Decision Process discussions of cross-specialty care Care Planning Refinement planning and process refinements. Team Required: Team Required: Team Required: For all three types of group decisions, Doctor, nurse, relevant Relevant specialists and Specialists, GP2, nurse, organisations should continue to fine- allied health professionals allied health professionals case manager, allied tune the processes used to bring the health professionals groups together to ensure decisions are made as effectively as possible. Meeting Frequency: Meeting Frequency: Meeting Frequency: Daily Weekly Monthly

SIBR®1 Case Review Conferences

1) Structured Interdisciplinary Bedside Rounds. 2) General Practitioner. Source: Advisory Board interviews and analysis.

The ward round is the hallmark of Rounds Lack Timing, Coordination Necessary for Effective Decisions making day-to-day care plan changes. Yet the traditional model in which different clinical roles round separately is not fit for complex patient care.

The sheer amount of information Doctors, Care Team Often Round Separately collected and decided upon during a single ward round for a patient with multiple conditions is extremely Decisions Currently Made on challenging to deliver to a care team Inadequate Information member not there in the moment. Later Ward Nurse Doctor Allied Health decisions are either made poorly 07:00 09:30 11:00 “Up to 400 decisions about without necessary information or are investigations and interventions may slowed down so that the information be made on a single ward round— can be tracked down. often on the basis of inadequate information because results are not available, key people cannot be contacted, and everything is done unsystematically.”

“What’s Wrong with Ward Rounds?”, Postgraduate Medical Journal

Additional caregivers for multimorbid patients

Source: Launer J, “What’s Wrong with Ward Rounds?” Postgraduate Medical Journal (2013), http://www.medscape.com/viewarticle/815063; Advisory Board interviews and analysis.

Organisations recognise the Interdisciplinary Rounds Aim to Solve Coordination Challenges shortcomings of traditional rounds and significant work has been done to shift clinical teams to a better decision- LOS and Cost Benefits of Benefits of Interdisciplinary Rounds making process. Interdisciplinary Rounds for Staff and Hospital

Largely considered a far more effective 6.1 Days Providers who Greater understanding of 5.5 Days participate in patient care rounding model, interdisciplinary interdisciplinary rounds address decision errors and rounds report: More effective delays by bringing together the full care communication team at the same time to collaborate on patient care. Both clinical evidence Enhanced interdisciplinary and hospital experience indicate that teamwork interdisciplinary rounding is indeed an improvement over traditional rounding practice. “Gold Standard” Interdisciplinary Model Traditional Interdisciplinary Rounding Rounding “If you’re looking for gold standard, you have to be able to have some way to have an interdisciplinary discussion. I think the people in the room need to be $8,090 $6,681 the key decision makers both medically and from Mean total charges in US dollars the family.” Chief Medical Officer, Canadian public hospital

Study in Brief: A Firm Trial of Interdisciplinary Rounds on Inpatient Medical Wards

• Interdisciplinary rounds designed at MetroHealth Medical Center in Cleveland, Ohio, US, includes doctors, staff nurses, nursing supervisors, and representatives of other disciplines, including respiratory, pharmacy, nutrition, and social work • Six-month trial showed statistically significant quality gains, improvements to staff satisfaction, length of stay reductions, and cost reductions in the interdisciplinary group • Interdisciplinary rounds instituted on all medicine inpatient services after trial

Source: Curley C, et al., “A Firm Trial of Interdisciplinary Rounds on the Inpatient Medical Wards: An Intervention Designed Using Continuous Quality Improvement”, (1998), Medical Care; Advisory Board interviews and analysis.

However, interdisciplinary rounding Hospitals Struggling to Make Rounds Effective for Complex Patients comes with its own set of issues, which are exacerbated when providing care to complex patients.

First, because clinicians are on different schedules, essential staff Challenges That Undermine Interdisciplinary Rounding often do not make it to the rounds. This becomes even more likely as the care 1 2 3 4 team grows larger for complex No-Shows Time-Intensive Patient Not Involved No Next Steps patients.

Next, many interdisciplinary rounds are Essential staff don’t Lack clear structure, Patient and family not Next steps not decided, poorly structured and take precious prioritise attendance too time consuming participants in rounds tasks not assigned time out of busy schedules. With a larger care team, this inefficiency is Complex Patients Complex Patients Complex Patients Complex Patients magnified. More clinicians, greater Large care teams delay Decisions require patient More complexity, more chance of no-shows information sharing info, decision input tasks requiring follow-up Additionally, patients and family are often not involved in the rounding process, even though they may have critical information necessary for a Talking Shouldn’t Be Difficult decision. “A patient who is unwell, tired, and not in the best of spirits, is being asked to continuously repeat Finally, despite bringing the full group their story. And if I was a patient, I would think, ‘This is just crap! Why don’t these people just read together, interdisciplinary rounds do what I told them previously?’ As a patient, I’m thinking, ‘These people don’t talk to each other’— not guarantee next steps are decided which they don’t.” upon and tasks are assigned, both of Clinical Director, Australian public hospital which become even harder when treating a patient with multiple conditions.

Source: Advisory Board interviews and analysis.

Ward leaders at Orange Hospital in Embedding Highly Structured Interdisciplinary Rounds New South Wales, Australia, recognised that their ward processes Building Blocks of Structured Interdisciplinary Bedside Rounds were not optimised to deliver effective patient care. Their ward rounds were failing to deliver good information fast Rounding Structure Attendees enough to prevent mistakes and keep • Introduce patient, review case • Patient, family length of stay down. • Summarise overnight; safety check • Junior doctor To improve care, the team decided to • Allied health, pharmacist, discharge • Consultant pilot Structured Interdisciplinary planner summarise plans • Bedside nurse ® Bedside Rounds (SIBR ), a • Patient, family ask questions programme originally developed at • Nurse unit manager Emory Healthcare in the US and • Outline daily plan; discharge estimate • Allied health (i.e., OT2, PT3, SW4) adopted in parts of New South Wales • Pharmacist through the work of the Clinical Excellence Commission (CEC). Jason Stein, MD, associate vice chair for Timeliness, Structure Keys to Sustaining Interdisciplinary Round quality in the Department of Medicine at Emory University School of “It is undoubtedly a constant piece of work to maintain the absolute rules about punctuality. The Medicine, helped the CEC adapt only way this is going to work is if the rounds start at exactly the same time, and everyone knows that. The allied health team knows, the nurses know—everything is geared to that.” Emory’s model of care across hospitals in New South Wales, Australia.1 Gabriel Shannon, Adjunct Associate Professor, University of Sydney

Orange Hospital chose SIBR® because it addressed the common challenges of What Is “SIBR®”? Fundamental Principles of SIBR® rounding through a highly structured yet flexible process. 1 Interdisciplinary Communication • Structured Interdisciplinary Bedside Round 2 Patient Safety • Model invented by Jason Stein in US 3 Patient-Based Care • Geographical co-location, patient involvement key distinctions 4 Development of Team Structures • Adoption of model in US and NSW5 5 Ground Rules

1) Dr. Stein has served as a paid consultant to the Clinical Excellence Commission of New South Wales on this care model. 2) Occupational Therapist. 3) Physiotherapist. Source: Orange Health Service, NSW, Australia; Clinical Excellence 4) Social Worker. Commission, NSW, Australia; Advisory Board interviews and analysis. 5) New South Wales. ©2015 The Advisory Board Company 31972 84 advisory.com A Highly Choreographed Endeavour

At Orange Hospital, the team used the Ensure Process Is Fit for Challenges Presented by Complex Patients SIBR® methodology to focus on four critical components of rounding: ®1 maintaining full round attendance, SIBR Addresses Common Challenges of Rounding keeping the rounds quick, actively involving the patient and family, and 1 2 3 4 delineating clear next steps post-round. Full Attendance Time-Efficient Active Patient Role Clear Next Steps

Use staff input to avoid Rounds structured to Set time for patient, Owners and tasks scheduling conflicts save clinician time family participation tracked in real-time

Committing to a Moment to Share Information “Yes, you can do your rounds in your old way if you like, but we all agree to have this one moment to share information. That has been hard, both with new registrars and new consultants. But I think once they do it, they realise they get so much information out of the round.”

Darryl Mackender, Acting Medical Director, In Safe Hands Ward, Orange Health Service

Case in Brief: Clinical Excellence Commission (CEC) • Commission established in 2004 to promote and support improved clinical care, safety, and quality across the public health system in New South Wales, Australia • Responsible for development and introduction of rounding model to Orange Health Service; CEC efforts have led to implementation of the rounding model in more than 70 units, from general medical to highly specialised, in 40 hospitals across New South Wales

1) Structured Interdisciplinary Bedside Rounds. SIBR® is a trademark protected by US and Source: Orange Health Service, NSW, Australia; Clinical Excellence international trademark laws, and administered and controlled by Centripital, Inc. Commission, NSW, Australia; Advisory Board interviews and analysis.

SIBR® rounds require all care team Staff Input Used to Ensure Rounds Work for Everyone members be present for the round, but this can be extremely challenging to achieve when clinicians have differing schedules and outside responsibilities. Identify Potential Problems of Each Staff Group, Collaboratively Develop Solutions The SIBR® methodology addresses this challenge by ensuring clinicians Staff Initial Problem Solution Benefit of New System are unit-based and realigning their schedules to align with one another. Doctors Difficult to reconcile doctors’ Doctors assigned to SIBR® Consistency in schedule– private practice responsibilities ward for 1 week, then off for doctors no longer torn However, that is a major shift for most with rounding schedule 4-5 weeks between private practice and clinicians, and will only work if they are acute medical patients fully onboard for the change. Nurses Tight schedule during morning Order of patients seen Improved access to and shift leaves little time for made flexible; nurses can communication with At Orange, team leaders made an added meeting present their patients in medical team on patient care effort to discuss the shift in staffing and immediate succession decisions rounding with each care team constituency. Leaders described what Allied Schedules do not align with Able to selectively Receive updated information SIBR® rounds were and what changes Health traditional rounding structure, only participate in rounds for on care plan from doctors were necessary. They also encouraged need to see specific patients necessary patients and nurses clinicians to tell them what problems SIBR® rounds would probably cause on the ward.

This process allowed Orange to identify each groups’ barriers to Case in Brief: Orange Health Service change and make SIBR® work for • 220-bed hospital in Orange, New South Wales, Australia, serving a population of about 250,000 them. Ultimately, leaders could show how the new model would benefit all • First hospital in NSW to implement SIBR® rounds, an interdisciplinary rounding structure clinicians. invented by Dr. Jason Stein of Emory Healthcare in the US • Working with Dr. Stein, CEC experts and Orange Health Service staff developed and piloted a custom, structured, and efficient rounding process tailored to the Australian public system

Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis.

Even with all clinicians bought-in and SIBR® Promotes Better Information Gathering, Boosts Team Commitment present at rounds, rounds can still be so inefficient that they grossly misuse precious clinician time.

SIBR® rounds reduce inefficiency by setting out clear guidelines for when Structured Morning Schedule the round will start, how long it will Key to Success of Model take, and how long each patient can be discussed. Time Task

Orange Hospital found that even this 07:00 Residents and consultant round Time Efficiency Through Schedule Rigor structure wasn’t enough to maintain on sickest patients; address “I don’t think any of us think we could have efficiency if clinicians came to the overnight concerns taken care of 30 or 35 patients before lunch round unprepared to discuss their rounding the old way—that would have patients. To maintain the round as a 08:00 Formal handover, all units taken us until 3 or 4 o’clock in the afternoon. Now, we get them sorted out by clear time for decision making, leaders 08:30 Consultant rounds on bed-blocked 1 o’clock. Most of those consultants that structured the morning hours before admitted patients in ED have other commitments are able to wrap the round for information gathering. up at 1 o’clock and go do something else.” 08:30- Senior doctors, junior residents, With medical and nursing rounds Gathering Information 10:00 medical students see all ward Darryl Mackender, Acting Medical Director, accomplished before SIBR® rounds, patients before 10:00 In Safe Hands Ward, Orange Health Service, the team can come together quickly to 10:00 First SIBR® Round New South Wales, Australia make decisions on care changes (first 13 patients) before going back to their other tasks. 11:00 Second SIBR® Round Shared Shared Structuring the hours leading up to the (second 13 patients) ® rounds has made not only the SIBR Making Decision rounds more efficient, but also the entire day more efficient for clinicians on the ward.

Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis.

Involving patients and their families in Guide Clinicians on Effectively Engaging Patients, Families decision-making processes is often seen as time consuming and is frequently left out of rounding processes. However, many of the decisions made during rounds could benefit from in-the-moment comments Orange’s Steps to Involve Patients Clinical Operations Board’s Practices from the patient and their family, in SIBR® Rounding Practice to Structure Patient Involvement especially if that patient has multiple conditions or specific challenges in the Established protocol to avoid jargon EMR1 system automatically translates community that the hospital team and speak in plain language medical terminology into patient would be unaware of. 1 understandable to patients friendly language Orange Hospital used the SIBR® round One-on-one rounding and patient structure to incorporate patient and Dedicated time at the end of experience simulation training provide family involvement into the rounding each round to respond to doctors the time and skills necessary to 2 patient, family questions process without derailing the meeting. engage patients in care Each patient rounded on is given dedicated time to ask questions or Maintained efficiency by Decision aids provide a framework for make comments on what the care 3 following up on questions that shared decision making between patients team has discussed. If a question would breach time limit and doctors would take too long to answer within the time limits of the SIBR® round, then a team member commits to following Please see the Special Report (page 101) for up on the question once the round has additional resources on patient engagement. finished.

Additionally, leaders at Orange have banned jargon from the rounds, requiring clinicians to speak about care decisions in language the patients will understand.

Source: Orange Health Service, NSW, Australia; Clinical Excellence 1) Electronic medical record. Commission, NSW, Australia; Advisory Board interviews and analysis.

Finally, Orange Hospital recognised Determine Daily Plan and Task Ownership Before Round Finishes that their rounding process redesign would not be successful unless they could ensure clinicians adhered to the decisions made and next steps outlined in the rounds. Components of Effective Next Steps Round Documentation Template The team now uses a standardised template to record discussion during the SIBR® round and update the patient’s plan for the day. The template has space for next steps to be Use standardised template to summarise recorded, and the team commits to discussion, record patient’s plan for the day, take the time to assign clear task and update expected date of discharge ownership at the end of each round.

Next steps are typically larger tasks that are deliberately saved to be done after the round ends, to maintain round efficiency. Smaller tasks are completed Create task list based on information shared during the round, as possible. during round and assign clear task ownership

Save larger tasks to be done after round

Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis.

Orange Hospital committed to a drastic Initial Data Shows Operational and Quality Gains change in ward processes when they decided to use the SIBR® rounding model. That commitment and the way in which Orange has implemented the rounds has paid off, with impressive Effective Bed Occupancy Length of Stay improvements in both ward efficiency 9% decrease and quality metrics. Capacity Improvements Days in LOS 95% 5.6 5.1 80%

Before SIBR® After 1 Year of Before SIBR® After 1 Year of Rounds SIBR® Rounds Rounds SIBR® Rounds

Quality Improvements

Decrease in Reduction in duration Increase in 15% ward mortality 50% of catheter in situ 100% VTE1 prophylaxis

Source: Orange Health Service, NSW, Australia; Clinical Excellence 1) Venous thromboembolism. Commission, NSW, Australia; Advisory Board interviews and analysis.

Due to the positive impact of Organic Growth a Testament to Impact implementing SIBR® rounds on the general medical ward, Orange Hospital is working to roll out the rounds to other wards. Expansion of Model at Orange Other Organisations Taking Notice International expansion: Widespread Beyond Orange Hospital, SIBR® Initial launch: Combined 8-bed medical assessment unit and implementation in US, over 70 wards in rounds continue to grow in use 18-bed acute medical unit NSW, piloted in Ontario, Canada globally, with organisations committing to the structured model hospital-wide. Newest expansion: Cardiology Expansion in Orange: Local GP-run ward created cardiology-specific hospital implemented structure safety checklist organisation-wide

Upcoming growth: Full New commitments: Liverpool Hospital implementation forthcoming in NSW expanding model throughout in surgical ward entire hospital

Teamwork Has to Be the New Model of Care “I don’t think anyone would go back to the way it was before. Not that the way it was before was particularly bad, but when you see what you can actually do, I think we know that it’s enormously different. That’s the way things are heading, that’s what we know—all the evidence indicates teamwork has to be the new model of care. The doctor gods and all that stuff are gone.” Gabriel Shannon, Adjunct Associate Professor, University of Sydney

Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis.

Certain care decisions will require an More Coordination Needed to Get Larger Teams Together even larger group, but the larger the group, the harder it is to bring it together.

Multimorbid patients often need cross- specialty care planning, but specialist Team Composition Dictates Frequency of Group Decisions doctors are extremely challenging to bring together.

The processes through which clinicians care for multimorbid patients continue to evolve as organisations find ways to Day-to-Day Care Changes Cross-Specialty Decision Process standardise care as much as possible, Care Planning Refinement but process refinement ideally involves a cross-continuum group of clinicians. Team Required: Team Required: Team Required: Doctor, nurse, relevant Relevant specialists and Specialists, GP, nurse, Effective case review conferences offer allied health professionals allied health professionals case manager, allied organisations a way to bring larger health professionals groups together for short amounts of time while still allowing for effective Meeting Frequency: Meeting Frequency: Meeting Frequency: decision making. Daily Weekly Monthly

SIBR®1 Case Review Conferences

1) Structured Interdisciplinary Bedside Rounds. Source: Advisory Board interviews and analysis.

Currently, very few structures exist to Routine Interdisciplinary Meetings Focused on Eliminating Siloes effectively manage communication and collaboration across multiple specialties or sites of care when caring for complex patients.

While better interdisciplinary rounding Steps to Transforming Complex Patient Care can improve decision making for day- to-day care, it does not address the PRESENT FUTURE broader care planning challenges inherent in caring for multimorbid patients. 1 Prioritise the right patients Case review conferences allow Unstructured Complex for the right clinical interventions Complex Patient organisations to bring together Care Management Case Conferences clinicians to ensure patients are receiving the right care and that teams • Fragmented care delivery 2 • Integrated care delivery, are in agreement on that care. Beyond • Poor communication and Engage doctors in eliminating treatment pathways agreement, the conferences also collaboration across silos within the hospital (and • Consistency in provide a forum for clinicians to identify providers potentially outside the hospital) utilisation practices opportunities to improve current care • Little standardisation • Systematically around clinical evidence integrating lessons from processes for complex patient and widespread quality 3 current complex care management. and cost variation management strategies Identify improvement opportunities in managing complex patients

Source: Advisory Board interviews and analysis.

As with SIBR® rounds, case review Case Criteria, Structure, and Process Refinement Critical to Success conference success ultimately rests on the effectiveness of the process itself. Because the conferences bring together large groups of clinicians, discussions and decisions can be rendered ineffective by any part of the Key Strategies to Optimise Case Conferences process that is inefficient. Proper Case Selection Organisations that have succeeded 1 with case review conferences focus on Prioritising the right patients through getting three areas right: case a rigorous case selection process selection, in-conference structure, and care process refinement. Adventist Medical Center, 2 Ideal Conference Structure Oregon, US Establishing routine meetings with clear agenda and ensuring staff attendance

3 Proactive Learning Process Taking steps to identify opportunities for quality improvement measures Kaiser Permanente, and refining care process California, US

Source: Adventist Medical Center, OR, US; Kaiser Permanente Southern California Region, CA, US; Tuso P, et al., The Permanente Journal, 2013, 17: 58-63; Advisory Board interviews and analysis.

Hoping to tackle high readmission Complex Patients at the Centre of the Discussion rates for their cardiovascular patients, Adventist Medical Center in the US recognised a need for cross-specialty Adventist’s Selection Criteria for Conference Cases collaboration to improve care management for patients that had a Review Criteria cardiovascular condition coupled with Instituted criteria to ensure comorbidities. value of meetings and prioritise complex patients Adventist’s cardiovascular leadership team implemented case review Risk-stratification based on geographical distribution, conferences in an attempt to improve having identified that patients in the secondary service cross-specialty collaboration. Cardiovascular Executive areas require more care coordination Director met with doctors Would benefit from multidisciplinary evaluation due to At first, there were no strict selection to explain standards comorbidities and complexity guidelines for cases, and doctors were asked to bring patient cases that they Has already had initial doctor work-up believed merited cross-specialty Either inpatient or outpatient at high-risk of readmissions discussion.

But, after a few conferences, leaders realised that these cases were not necessarily the patients that could benefit from group decisions the most, Case in Brief: Adventist Medical Center nor were they an effective use of the • 302-bed hospital in Portland, Oregon, US group’s time. • Upon developing a Medical Staff Department of CV1 Medicine and Surgery in 2009, CV administrator Leaders developed and disseminated recognised a need for more structured multidisciplinary collaboration, particularly for complex CV cases selection criteria to ensure that proper • Established a weekly high-risk CV case conference, offering CV doctors the opportunity to discuss cases were picked for the meetings. complex patients with a variety of specialties and develop an informed care plan. Attendees include a Doctors still had control over which cardiologist, CV surgeon, anaesthesiologist, intensivist, hospitalist, pulmonologist, interventional patient cases were discussed, but the radiologist, and CV physician assistant criteria helped maintain meeting quality • Have received very positive feedback from doctors, who enjoy the opportunity to learn from peers and and maximise patient benefit. enhance multidisciplinary collaboration

1) Cardiovascular. Source: Adventist Medical Center, OR, US; Advisory Board interviews and analysis.

Structuring the case conference to be Guaranteeing Meetings Are a Productive Use of Doctor Time convenient for participants is as essential to the sustainability of the process as proper case selection.

At Adventist, leaders knew that specialists were unlikely to participate if Adventist Medical Center’s High-Risk Case Conferences the session was difficult to attend or inefficient in any way.

To prevent meeting burnout, the conferences are held only once a week for an hour, with a strict meeting Rigorous Structure Thorough Preparation Convenient for Participants structure that allows the group to • One-hour weekly meetings • Attendees submit patient IDs2 • Held at lunchtime with discuss four to eight cases per • Invite range of specialists in CV1 for proposed cases the day food provided conference. and common comorbidities before • Convenient campus 3 So that the conference is purely • CV doctors present complex • CV assistant pulls PACS and location for all specialties blinded records for each discussion and solution based and not cases to gain peer insight and • Consistent time, location, patient to project during bogged down in administrative tasks, develop informed care plans and frequency to become meeting all proposed cases are due the day • Each session, discuss 4-8 cases part of doctor routine • CV Executive Director leads 4 before and an assistant prepares with a variety of diagnoses • Offers CME credits meetings, following the agenda blinded records to be projected during the meeting. An executive director leads the conference to keep to the set agenda.

The team also made the conferences as easy to prioritise as possible. The conferences are held at a consistent time and location convenient to all involved with lunch provided, aiming to cement the conference as a part of the doctors’ routines. As an added incentive, the conferences count 1) Cardiovascular. towards doctors’ continuing medical 2) Identification details. 3) Picture Archiving and Communication System (PACS) is a medical imaging technology which provides education requirements. economical storage of and convenient access to images from multiple modalities (source machine types). 4) Continuing Medical Education. Source: Adventist Medical Center, OR, US; Advisory Board interviews and analysis.

Finally, case review conferences Refining Care Processes for Future Complex Patients present a unique opportunity to bring together a larger group of clinicians to refine care processes for complex Kaiser’s Monthly Conference Assembles Full Spectrum of Caregivers patients.

Like Adventist, Kaiser Permanente Southern California Region in the US Community-Based Attendees Hospital-Based Attendees hoped to improve care for comorbid patients through case conferences. • GP • Hospitalist But, rather than focusing purely on • Continuing care • ED/urgent care cross-specialty collaboration within the • Care managers • Quality team lead hospital, Kaiser broadened the scope (HF1, ESRD2) Community Hospital • Cardiologist of the conferences to include • Social services community-based members of the • Nephrologist patients’ care teams. • Pharmacist • Other specialists Because the group involved spans care settings, Kaiser has case conferences only once a month for an High-risk cases discussed to develop collaborative in-depth look at one to two high-risk 2 care plan and identify opportunities to enhance patient cases. The group discusses the system-wide care management cases and reaches a decision on what care management should look like for those two patients at any point in the system. Case in Brief: Kaiser Permanente Southern California Region (KPSC) From those discussions, the group identifies anything that could be used • 13-hospital health system based in Pasadena, California, US to enhance care for similar patients • In 2011, established a cross-continuum complex disease case conference, which brings together an throughout the system. interdisciplinary team from hospital and outpatient settings to identify opportunities for system-wide care coordination improvement • Eventually rolled out conferences across all sites, resulting in significant improvements in care coordination

1) Heart failure. Source: Kaiser Permanente Southern California Region, CA, US; Tuso P, et al., 2) End stage renal disease. The Permanente Journal, 2013, 17: 58-63; Advisory Board interviews and analysis.

Kaiser’s case conferences are useful Productive Meetings Create Efficient Processes not only to the two patients discussed, but also to other patients in the health system. How Kaiser Uses Case Conferences to Create Better Complex Patient Pathways For example, discussion from the first few conferences revealed that high-risk complex patients were being referred to palliative care services too late in 1 2 3 their treatment. These late referrals were undermining the patients’ Root Cause Analysis Solution Development Best Practice Rollout experience and driving unnecessary utilisation of hospital services. Example in Practice Example in Practice Example in Practice Case discussion revealed Team developed protocol to Identified palliative care patients From this discovery, a team was complex patients often referred hardwire early palliative care transferred to end-of-life plan as to palliative care too late, leading consults and embedded risk needed; shared risk tool and system- tasked with developing a protocol to to unnecessary utilisation and score into EMR1 to determine wide protocol, enabling widespread ensure early palliative care consults poor patient experience appropriate patients impact of case conferences were available when appropriate, based on patients’ risk scores.

Based on the success of the initial rollout of this new palliative care Case Conferences Inform Clinical Practice protocol, the process was shared “The results from these conferences were informative. A key finding was that many physicians system wide. across different teams that cared for high-risk patients never met in person, although they might have talked on the phone. Another key finding was the observed benefit of having all team members Thus, while Kaiser’s case review agree on a unified treatment plan for the patients.” conferences are less frequent and discuss fewer patients, they capitalise “Complex Case Conferences Associated with Reduced Hospital Admissions for on the opportunity to make widespread High-Risk Patients with Multiple Comorbidites”, The Permanente Journal improvements to complex patient care.

Source: Kaiser Permanente Southern California Region, CA, US; Tuso P, et al., 1) Electronic medical record. The Permanente Journal, 2013, 17: 58-63; Advisory Board interviews and analysis.

The elements previously discussed across Adventist’s and Kaiser’s examples are essential to productive case conferences.

Adventist credits their case conferences with improving Change in Number of Hospitalisations at Kaiser collaboration amongst specialties and Admissions to the Hospital streamlining complex patient care n=21 Patients with Heart Failure Reviewed in Case Conference management and decision making. 81 Kaiser has seen benefits from their Case Conference Tools conferences as well, with a large 68% reduction in Please see Templates and Tools reduction in readmissions among the hospitalisations complex patients already discussed section for details on: and widespread process changes • Kaiser’s Complex Disease Case stemming from problems uncovered Conference Charter (page 130) 22 during the conferences. • Kaiser’s Complex Disease Case Conference Agenda (page 132)

Six months before a CCC Six months after a CCC

Source: Kaiser Permanente Southern California Region, CA, US; Tuso P, et al., 1) Complex case management conference. The Permanente Journal, 2013, 17: 58-63; Advisory Board interviews and analysis.

Patients: The Untapped Resource

The great untapped resources are patients and families themselves, and getting structures and systems in place that allow patients and families to contribute more to care is essential.” Hospital executive and doctor New Zealand public hospital

Much of the decision-making process for complex care depends upon how well the clinical team collaborates and communicates to make decisions. Opportunities for Patient Involvement to Enhance Decision Making Effectiveness Necessarily, then, hospitals should focus on improving how the clinical team makes decisions. Information Exchange Joint Decision Making But focusing completely on improving clinician collaboration and • Inform patients and caregivers of • Engage patients and caregivers communication misses the larger point: care plan in lay terms to ensure their to determine needs, preferences care decisions are made for and about understanding • Establish clear understanding and patients, who should therefore be • Solicit details about their conditions, expectation of treatment options considered an integral part of the care symptoms, and home care • Align treatment plan with patients’ team. Patient involvement can even circumstances to treat effectively needs and preferences enhance the decision-making process.

Improvements to decision making must take into account how clinicians interact with patients and families and examine when it is best to have the Patient Ownership of Care Is Ideal patient be the decision maker. “We kind of learned the hard way. Time spent listening to and learning from our patients actually results in cost savings for us down the line.” The broader strategies applied to Patient Experience Lead, NHS Trust, United Kingdom improving clinical decision making can be applied to involving patients in the decision-making process.

Clinicians need to share and receive information effectively from patients. There needs to be a clear decision owner, whether that be the lead clinician or the patient. Finally, there must be structured processes to engage patients in their care to ensure engagement is consistently happening.

Source: Advisory Board interviews and analysis.

Most organisations recognise the value of patient involvement in care and set it as a top priority. However, successful patient involvement is still a work in Infrequent Patient Involvement Ineffective Patient Involvement progress. Organisations continue to struggle with both infrequent and ineffective patient involvement. of Dutch patients1 reported of British patients1 reported Though patient involvement may be a 49% they did not discuss their 35% they were not encouraged strategic goal for organisations, front- main health goals with a by their doctor to ask line staff are often unaware of its member of the care team questions about their importance or see it as too time- condition or options consuming to incorporate into their clinical practice. Root Causes Root Causes Even when patients and families are involved in care planning and decisions, clinicians can fail to deliver information effectively or patients can Staff Don’t Staff Fail to Patient, Family Patient Lacks have barriers to productive See Value Prioritise Poorly Informed Capacity participation. Unaware or Consider patient Staff seek patient Psychosocial dismissive of involvement overly participation, but issues present patient-led care time consuming do not successfully significant barriers planning educate on conditions to effective and treatment options patient participation

Source: Schoen C, et al., “In Chronic Condition: Experiences of Patients with Complex Health Care Needs, 1) With at least one chronic condition. in Eight Countries, 2008”, Health Affairs, 28 no.1 (2009); Advisory Board interviews and analysis.

With complex patients, the importance More Important, Yet More Difficult, to Activate Complex Patients of involving patients in the decision- making process is magnified.

Complex patients and their families The Challenge of Involving Complex Patients often have information that would be critical to clinicians when deciding amongst treatment options, but that only they know.

These patients also have an increased Critical Importance Extreme Challenge need for successful care planning and management of their multiple conditions to prevent a readmission to Patient, family experts in Complex medication the hospital. For this to be effective, the holistic history and symptoms reconciliation needs patient and their family must understand the conditions and how to Alignment of care goals Consultations and follow-ups with manage them at home. necessary multiple hospital-based specialists

Unfortunately, involving complex Chronic care self-management Mental health and dementia support patients in their care is also much more for multiple conditions challenging to do effectively. Complex patients have many conditions to Complex care decisions Caregiver and family manage at the same time, with all of require patient and family input support necessary the accompanying medications and appointments. They may also need mental health support or be dependent on caregiver and family support to manage their conditions.

Source: Advisory Board interviews and analysis.

While a critical component of improving decision making for complex patients, involving patients in decisions is a large topic on its own, worthy of further research. Key Strategies for Involving Patients and Family in Decision Making

This special report provides case studies to aid organisations in their Build Patient Engagement Culture Among Doctors quest to improve patient involvement in 1 Engaging Doctors in Patient Experience decisions, but it should be considered an introduction to the Clinical Improve Information Exchange Operations Board’s resources on 2 Abington Memorial Hospital, US patient involvement.

Our research provides strategies to Enable Joint Decision Making tackle the major root causes of poor 3 Ottawa Hospital Research Institute, Canada patient involvement, such as low clinician comfort to involve patients.

All additional resources can be found at advisory.com/cob/ patientengagement.

Source: Advisory Board interviews and analysis.

Many doctors view patient engagement Overcoming a Key Root Cause: Clinician Comfort or experience initiatives as tangential to their mission as doctors—to provide their patients the best care possible. In reality, patient engagement is central to Implementation Strategy for Building a this quality mission. Research shows Patient Engagement Culture Among Doctors that through the doctor’s leadership of and communication with the care team, he or she has the ability to drive patient engagement and experience Strengthening Doctor Skills improvement more than any other clinician in the enterprise. Engaging • Workshops target and develop Influencer-in-Chief doctor-patient involvement Even when doctors have the will to skill set improve their patient engagement Skill Leading • All new staff participate in basic • Develop doctors as patient performance, they often lack the Development Institutional Change patient involvement training and involvement leaders knowledge or the means. onboarding • Target low performers and • Patient engagement supported • Key staff groups prioritised for provide additional training, Organisations must provide doctors by executive leadership, further training shadowing/coaching programme with the necessary skills and support to instituted as a cultural norm excel as patient engagement providers. Reinforces Institutional Commitment This study showcases best practices for leveraging doctors’ patient Doctor Investment and Commitment experience data as a first step to improving performance. It also explores coaching, training, shadowing, and the use of low-tech tools to develop and leverage doctor empathy and communication skills. For more information, please see advisory.com/cob to access the study Engaging Doctors in Patient Experience

Source: Advisory Board interviews and analysis.

At Abington Memorial Hospital in the Staff’s Lack of Time to Fully Explain Care Plans Identified as Primary Cause US, nursing leaders realised that patients were unsure how to manage their care and were getting increasingly frustrated.

Leaders identified poor or nonexistent Abington Memorial Hospital’s Journey to Creating Informed Patients transfers of information from clinicians to the patients and their families as the Nurses observed patient’s Recognised staff lack time to Received grant to primary cause of the problem. lack of involvement in fully explain care process and develop automated care and resulting problems plan to each patient patient report When clinicians were asked why they did not involve the patient, the most common response was that they Identified lack of Developed proposal to simply did not have the time to do so. information transfer to automate translated daily patient and family as driver care plans for patients

The Root of Patient and Family Frustrations “A few years back, we discussed how we could better get information to patients, because I saw that usually family frustration comes down to communication and not knowing what's going on— there’s confusion about what’s being done, what needs to be done. Eventually, the patients and their families become upset. We needed to address this without adding to the workload.”

Diane Humbrecht, Chief Nursing Informatics Officer, Abington Memorial Hospital

Source: Abington Memorial Hospital, Abington, PA, US; Advisory Board interviews and analysis.

Recognising that clinicians felt unable Automated Translation Delivers Easy-to-Read Daily Care Updates to spend time involving patients in their care, Abington knew it would 1 disengage staff to decree that they had Abington Memorial’s Daily Patient CARE Plan Process to involve patients anyway without any additional support.

Abington decided to automate the patient involvement process to take Translate Print Distribute Review some of the burden off of their busy clinicians. • IT team configured • EMR automatically • Nurse highlights • Plans kept in folder for translations to convert prints plans every important items on patient at bedside Every morning, nurses now receive a nursing terms to layman morning report • When doctor rounds, printed out care plan for their patients 2 terms (i.e., “b.i.d.” on a • Populates from same • Delivers it to patient reviews plans again that is pre-populated with data from the prescription became data as staff reports each morning with patient hospital’s electronic medical record. “twice a day”)

Perhaps most importantly, the care plan is automatically translated into language the patient can understand, using a translation algorithm in Case in Brief: Abington Memorial Hospital Abington’s electronic medical record. • A 655-bed hospital located in Abington, PA

Nurses use this report to engage • In 2005, automated daily Kardex, a nursing paper-based tool, and physically shared it with patients; Kardex includes patient’s doctors, diagnosis, medications, tests scheduled, and physical and outpatient patients in their care, sharing the therapy. Observed technical nature undermined value as patients struggled to comprehend data information at the bedside and leaving and information the printed care plan with the patient. When the patient’s doctor rounds, he • Nursing Informatics Director worked with EMR vendor to automatically pull reports from hospital’s order or she can review the plan again with entries; IT department then hardwired layman’s terms translated into EMR the patient. • Since implementation, informing patients about their care plan has become a part of the organisational culture and significantly reduced the frequency of adverse events • CARE Plan has received Magnet recognition from the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program® three times, most recently in 20133

1) Communication, Access to Information, Resources & Education. 2) Bis in die = twice a day. 3) An organisation that reapplies for Magnet recognition must provide documented evidence of how Magnet concepts, performance, and quality were sustained and improved over the four-year period since the hospital received its most recent recognition. Source: Abington Memorial Hospital, Abington, PA, US; Advisory Board interviews and analysis.

Abington’s clinicians stressed that one Technical Jargon Transformed into Easy-to-Understand Terms of the most time-consuming components of involving patients in their care was taking clinical 1 information and delivering it in a format The Abington Memorial Daily Patient CARE Plan patients could understand.

With the automatically translated care Abington Memorial Hospital plan, the barrier to engaging patients is Your Personal Guide for Communication, Access to Information, Resources & Education dramatically lessened. SMITH, ANGEL 2H-2H05N2 Admit Date: 05/18/2015 The care plan shown here is RES IM-D7 #7607 representative of the document that nurses receive each morning. Clinical Respiratory Care information is documented on the left O2 Therapy Cannula 2.0 LPM (continuous) A way to deliver needed oxygen to help and is translated for the patient on the you breathe better. right. Oximetry (Resp) Routine (one time) A test to check the percent of oxygen in your blood.

Laboratory CK w/ Reflexive MB 1100 Lab Rounds A blood test that measures the amount of muscle enzyme in your blood.

Cardiac Troponin 1100 Lab Rounds A blood test that measures the amount of cardiac protein in your blood.

Low Barriers to Entry “Any EMR system can generate this report. If you have an EMR, you can create this report.” Diane Humbrecht, Chief Nursing Informatics Officer, Abington Memorial Hospital

1) Sample content; not an actual patient record. Source: Abington Memorial Hospital, Abington, PA, US; Advisory Board interviews and analysis.

The automated daily care plans have Avoiding Near Misses Easily Recoups $25,0001 Investment helped clinicians better involve patients in their care and thus helped improve overall care quality. Adverse Events Avoided During Three-Month Pilot Impact of Acute-Setting Adverse Events Within the first three months of piloting n=254 patients the care plans, patients and families Average cost of a hospital helped the care team avoid over 20 10 medication error: $4,300 31% adverse events by providing critical 8 information to clinicians. Average percent increase in hospital length of stay as a result of preventable adverse events As an added benefit to the important quality improvements, the avoided adverse events easily justified the 1 1 1 $25,000 investment required to automate the process. Medication Allergy Code Health Nutrition Status Issue

The Patient and Family as Safety Net Against Mistakes “We have caught patient's code status—what they want for resuscitation has been wrong. That's huge! It brings the patient into being more a part of the plan. The patient and/or their family at least now has information about their loved one or themselves about what's happening.”

Diane Humbrecht, Chief Nursing Informatics Officer, Abington Memorial Hospital

Source: Abington Memorial Hospital, Abington, PA, US; Forster, Alan, et al., “The Impact of Adverse Events in the Intensive Care Unit on Hospital Mortality and Length of Stay”, BMC Health Services Research, 2008, 8: 259; “Computerized Physician Order Entry Systems and 1) US dollars. Medication Errors”, The LeapFrog Group, 9 April 2015; Advisory Board interviews and analysis.

Without a doubt, striving to better Must Ensure Medical Expertise, Patient Goals Receive Equal Billing involve patients and their families in their care is a worthy goal. But, the extent to which control of decision making is shifted from clinicians to patients should be handled carefully. Use Clinical Staff Knowledge to Support Patient-Led Decisions On one end of the spectrum, medical staff fall into a pattern of dictating the direction of patient care, not always taking into account the patient’s goals Doctor Medically Sound, Patient and preferences. Preference Patient-Led Care Expectations

Yet on the other end, without a medical background, patients’ goals can be Shared Decision Making woefully misaligned with the realities of their conditions and care options.

Clinicians and patients must meet in Historically Collaboratively reached Without evidence- the middle, making decisions that draw paternalistic, doctors decisions create enhanced based knowledge, from the strengths that both sides bring dictate patient care buy-in for all parties, patient expectations are to the decision-making process. direction; often fail to as well as a greater often misaligned with account for patient likelihood of patient realities of condition preferences and goals adherence to care plan and treatment options

Source: Advisory Board interviews and analysis.

Collaborative or shared decision Equip Staff, Patients, and Caregivers to Find the Right Answers making is a significant step beyond sharing information with patients. If done incorrectly, shared decision Why Patient Decision Aids? Qualities of Effective Decision Aids making can be time consuming and • Clinicians often make care decisions Comprehensive, Evidence Based frustrating for both clinicians and without knowledge of factors that Provide medically complete information patients. influence a patient’s ability or willingness on treatment options, facilitating decision to adhere making for complex patients Shared decision making therefore must be a well-structured process to be • Patient-friendly aids allow collaborative Time Neutral successful. review of care options Use of appropriately designed decision aids consumes the same amount of time • Provides comprehensive, evidence-based One of the best tools organisations can as traditional practice data on each care option use to structure shared decision Consistent making is the decision aid. • Helps patients to understand trade-offs and long-term implications of Use of medically comprehensive aids Decision aids can be used for a variety care options ensures consistency in content delivery of conditions and decisions, but all • Evidence-based design ensures Engaging good aids have these qualities in medically informed decisions that align Decision aids enhance patient common: they are based in the most with patient preference, ability, and goals participation, information retention, and up-to-date medical evidence available commitment to plan and they are as time neutral as possible when compared to traditional practice.

These aids, when used correctly, ensure consistency in content delivery Signal, Structure, and Support across clinicians and patients. They also fundamentally enhance patient “50% of patients don’t even know there was a decision when one takes place. The use of the guides participation in the decision-making informs the patient that there is a decision to be made. They also provide balanced, complete information on options, benefits, and harm, which they wouldn’t necessarily receive without the guide. They empower process, increasing the likelihood that the patient to engage in their own medical decisions, and support physicians in navigating the patient patients engage with and commit to through the decision-making process.” their care plans. Dawn Stacey, Clinical Epidemiology Program, Ottawa Hospital Research Institute

Source: The Ottawa Hospital Research Institute, Ontario, Canada, http://decisionaid.ohri.ca; Informed Medical Decisions Foundation, Boston, MA, US, http://www.informedmedicaldecisions.org; Advisory Board interviews and analysis.

The Ottawa Hospital Research Institute (OHRI) in Ontario, Canada, provides one of the most comprehensive collections of publicly available Three Steps to Use Patient Decision Aids to Reach Informed Decisions international decision aids, along with guidance on how to most effectively use the aids. 1 2 3

To make shared decision making through the use of these decision aids as productive as possible, Communicate Using Highlight Key Pros Document Patient Patient-Friendly Language and Cons of Each Preferences in organisations should focus on three Treatment Option Patient Record steps. Leaders ensure decision aids Decision aids show side-by- Clinicians document patient First, decision aids and the language use clear language at a low side comparisons for different preferences in the EMR or clinicians use to go through them with reading level and incorporate treatment options–including patient record to inform visuals as appropriate to assist comparisons of cost, future decisions the patient must be at a level the clinicians in explaining medical potential side effects, and patient can understand. and financial implications of frequency of administration treatment options (for medications). Second, clinicians must provide side- by-side comparisons of treatment options, including a discussion of costs and potential side effects associated with each option.

Third, any decision made or patient Case in Brief: Ottawa Hospital Research Institute preference discovered or changed • The Ottawa Hospital Research Institute (OHRI) established a Patient Decision Aids Research Group, must be documented so that it can be dedicated to developing decision aids used to inform future care decisions. • Designed framework to guide the development of interventions aimed at preparing patients and doctors for shared decision making • Leads the Cochrane Review of patient decision aids for treatment and screening, combining studies from around the world that have evaluated patient decision aids • Provides an international inventory of publicly available decision aids along with approximately 300 shared decision-making tools, on a range of conditions and diseases, produced by the OHRI

Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis.

Many of the decision aids available through OHRI have a patient-facing component. Sample Decision Aid Available Through OHRI1 This takes patients through the entire decision, from gathering facts about their condition, to comparing options, to describing how the patient feels about the decision.

This also helps expedite clinician time, as patients have had time to review key information before engaging in the decision-making process.

1) Ottawa Hospital Research Institute. Source: The Ottawa Hospital Research Institute, Ontario, Canada, http://decisionaid.ohri.ca/; Advisory Board interviews and analysis.

While OHRI’s resources are some of the most comprehensive, there are several other organisations that also have excellent shared decision making Resource Description Sample Guidance, Tools resources that are available for public Ottawa Hospital Group designs decision aid, • Library of decision aids covering a range of use. Research Institute’s SDM1 training programmes, medical decisions Patient Decision Aid and evaluates techniques in • Implementation toolkit for incorporating SDM into practice Resource Group practice • Evidence from systematic reviews of shared decision making aids in practice Informed Medical Organisation dedicated to • Decision Aid Programmes for a range of conditions Decisions Foundation developing high-quality • “Introduction to SDM and Decision Aids” for providers patient decision aids, funding research and SDM • “Six steps of SDM for Providers” demonstrations, and • Events and summits on SDM advancing SDM through outreach and advocacy The Mayo Clinic’s The Center promotes SDM • Patient decision aids for a variety of chronic, complex Shared Decision through development and conditions Making National assessment of patient • Videos demonstrating suggested techniques for using decision Resource Center decision aids, and provides aids support and training for institutions looking to • Research results to support implementation of decision aids implement SDM • National and international conferences on SDM to advance research and educate providers Dartmouth-Hitchcock Center provides decision • Guides for programmes on starting a SDM centre, including job Center for Shared support guidance for patients descriptions, sample budget, etc. Decision Making and providers at Darthmouth- • Decision support skills toolkit for doctors and non-doctor Hitchcock, as well as providers provides resources to support other programmes in • Decision aid library of booklets and DVDs for patients implementing SDM, developing similar model

Source: Patient Decision Aid Resource Group, https://decisionaid.ohri.ca/about.html; Informed Medical Decisions Center, http://www.informedmedicaldecisions.org/; Mayo Clinic Shared Decision Making National Resource Center, http://shareddecisions.mayoclinic.org/; Center for Shared Decision Making, http://med.dartmouth-hitchcock.org/csdm_toolkits.html; 1) Shared decision making. Advisory Board interviews and analysis.

The Missing Piece of the Puzzle

Organisations around the world are …But Silos Still Impede Integrated Care Within the Hospital increasingly seeking to integrate care across the continuum to achieve better outcomes and make health care provision sustainable. Discussions of integration often revolve around designing a system around patient Silos Preventing Integrated Care Across Health System, Within Hospital needs—rather than around those of Examples of Cross-Continuum Silos Examples of Hospital-Based Silos providers—in an effort to better treat chronic, multimorbid patients. Acute Doctor Home Departments Professions Disciplines Hospital Office Health Too often, though, the focus on cross- ED Doctors Cardiologist continuum integration overlooks the versus versus versus fact that many silos still exist within ICU Nurses Orthopaedist hospitals, impacting how effectively patients can be treated during their hospital stays.

While cross-continuum integration is a necessary step to better manage complex multimorbid patients, hospitals must commit to improving internal integration to be a serious partner in broader changes. Getting Your Own House in Order First “Before you go asking social service, community care, or others to change the way they do business for you, you need to get your own house in order first. You can’t present yourself as a credible partner, or ask them to make changes, if you still have internal inefficiencies.” Hospital Executive, English public hospital

Source: Advisory Board interviews and analysis.

With the strategies delivered in The Unit-Based Redesign Required for Complex Inpatient Management New Normal, Clinical Operations Board members now have access to resources to improve the patient journey through the hospital from start to finish. Overview of Clinical Operations Board Resources Dedicated to Improving Inpatient Flow Taken together, these resources provide the pieces necessary to begin tackling hospital-based silos and transitions of care. The Emergency Redesigning Acute The Discharge Seamless Care Equipped with Clinical Operations Department Strategy Care for Complex Strategy Handbook Transitions (2011) Board research and tools, members Guide (2014) Patients (2015) (2014) can deploy strategies to integrate care Practices leveraging Unit-based best A strategic guide to Tactics in four key within the acute care enterprise. internal emergency practices to improve eliminating discharge areas to improve care department efficiency care for complex delays for complex, transitions for the most The Board’s sister programme, the improvements and multimorbid patients long length-of-stay vulnerable patient Global Forum for Health Care external partner along with guidance on patients as the greatest groups: targeting Innovators, specifically helps members cooperation to position expanding these opportunity to reduce patients, processes, the ED as an entry practices throughout length of stay and to and resources; looking to integrate care across the point for a growing an entire organisation make the most of preparing for post- entire continuum and better manage population of older, hospital resources discharge; enhancing complex patients in the community. more resource- post-acute care; and intensive and comorbid supporting patients in Taken together, this body of work patients the community serves to assist members as they begin to redesign health systems to better treat complex multimorbid Continuum of Care patients, who are increasingly Admission Discharge becoming The New Normal.

Source: Advisory Board interviews and analysis.

Emory Healthcare’s Signed Pledge Example and Cup of Coffee Conversations Guide ...... 122 ® SIBR Rounding Structure and Attendees ...... 128 ® SIBR In-Round Worksheet ...... 129 Kaiser Permanente’s Complex Disease Case Conference Charter and Agenda...... 130 Abington Memorial Hospital’s Daily CARE Plan ...... 133 Ottawa Hospital Research Institute’s Personal Decision Guide ...... 135 Ottawa Hospital Research Institute’s Advance Care Planning Decision Aid ...... 137

Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis. Emory Emory

Coaching or facilitating “Cup of Coffee Conversations”

Consider before the conversation:

1. Be clear about the message. Be clear about the specific behaviour the sender wants to address with the receiver.

2. Is the observed/reported behaviour one that should immediately be escalated to management and/or human resource?

3. Acknowledge the possibility that the behaviour may be something the receiver is not aware of; either the behaviour itself or the impact the behaviour has on others. (remember the JOHARI window)

JOHARI WINDOW

That part of me that I’m That part of me that I’m aware of, and freely share aware of, but try to keep with others… hidden from others…

That part of me that I’m not That part of me that I’m not aware of, but others are aware of, and others are not aware of… aware of…

4. Clarify the motive for having the conversation. Is the sender offering the feedback out of a spirit of teamwork and improvement?

5. Ask if the sender is calm enough to have the conversation. Does the sender have enough emotional distance from the behaviour and/or the event to deliver the message in a way that is both direct and sensitive/caring?

Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis.

6. Is the sender able to suspend any inferences drawn from the specific event/behavior, and focus on the behavior itself?

LADDER OF INFERENCE

CHARACTERISATION

GENERALISATION

INTERPRETATION

DATA

Conversation content:

1. Invite the receiver to a private location. Z “Hal, can we walk over to that empty room down the hall for a few minutes? I have something I want to ask you about.” Versus …launching into the conversation in a public place where others can hear you.

2. Invite the receiver into the conversation. Z “Hal, I’d like to talk with you about the interaction we had two days ago at the nurses’ station. Is that ok with you?” Versus “Hal, you need to hear some feedback I have for you.”

Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis.

3. Begin the conversation by shaping or referring to the goal…the vision. Z “Hal, I’d like to talk with you about how our communication on the unit can be more consistent with the Pledge…with promoting more effective teamwork here on our unit.” Versus “Hal, I’m sick and tired of the way you behave when you talk with me and other members of the care team on this unit.”

4. Describe how you felt and reacted to the behavior you want to address. Z “Hal, I felt defensive and reluctant to talk with you this morning when… I didn’t feel respected as part of the team.” Versus “Hal, all of the nurses on this unit are complaining about your behavior.” or “Your behavior is causing a breakdown in teamwork on this unit.”

5. Identify the specific behavior and circumstance you want to address rather than generalising. Z “Hal, I felt defensive and reluctant to talk with you this morning when you raised your voice to me and cursed at me while we were both working at the nurses’ station. I think you wanted to ask me about whether or not the procedure had been scheduled, but when you started raising your voice and cursing, it was hard for me to listen to you, and I didn’t feel respected as part of the team.” Versus “Hal, you’re always yelling at people on the unit. All of the other physicians on this unit are complaining about the way you behave.”

6. If possible, contrast the negative behavior to past instances of positive behavior. Z “Hal, I felt much more confident and respected last week when you asked me about Mrs. Smith. You weren’t raising your voice, you weren't using curse words, and it felt much more collaborative.”

Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis.

7. Set a tone of directness and sensitivity/caring. Don’t “beat around the bush”, and do offer the feedback out of a spirit of caring. Z Direct, but insensitive/uncaring: • “Hal, your behavior is killing any sense of teamwork we have on this unit.” Z Indirect but sensitive/caring: • “Hal, have you ever been in a situation where someone has said or done something that really bothered you, and you thought maybe they didn’t even realise they had said or done anything wrong, but you felt like it was important to talk with them, but you weren’t sure how to approach them…” Z Direct and sensitive/caring: • “Hal, I really value being on the same team as you. When you use curse words and raise your voice at me the way you did this morning, it makes me feel disrespected and even a little afraid to interact with you. I don’t want to feel like that. I want to be a good team member with you.”

8. Offer feedback that is descriptive rather than evaluative. Z Evaluative: • “Hal, when you were being such a jerk this morning…that was a perfect example of everything that’s wrong with this place.” Z Descriptive: • “Hal, when you used curse words and raised your voice this morning at the nurses’ station, it made me feel disrespected and a little afraid of you.”

9. Avoid using words and phrases that lead to defensiveness…words and phrases that are: Z Orders/directives • “What you need to do is…” • “You have GOT to start…” Z Warnings/threats • “You better not…” • “If I see you doing that again, I’ll…” Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis.

Z Preaching/Moralising: • “Don’t you know better than to…?” • “Most people learned this in kindergarten…” Z Diagnostic/interpretive: • “I think your problem is…” • “I know you must be under a lot of stress…” Z Unsolicited advice: • “If I were you I’d see someone about this…” • “Why don’t you make an appointment with someone from the employee assistance programme?”

10. Check to see if the receiver has heard what you and/or the sender intended to communicate. Z “Hal, I’m not sure if I’m doing a good job communicating this. What did you hear me say?”

Source: Emory Healthcare, Atlanta, GA, US; Advisory Board interviews and analysis.

Round Structure Round Attendees 1. Introduce patient, review case • Patient, family • Lead team into room • Junior doctor • Introduce team members • Consultant • Summarise active problems • Bedside nurse • Provide updated investigation results • Nurse unit manager • “Waiting for What”? • Allied health (i.e., Occupational Therapist, Physical Therapist, Social Worker) 2. Summarise overnight events, safety check • Pharmacist • Drips and drains (Cannula, catheter, etc.) • VTE1 prophylaxis • Falls risk • Pressure injury 3. Allied health, pharmacist, discharge planner, summarise plans • Update on progress of the patient • State priorities for the day 4. Patient, family ask questions • Invite input from patient and family 5. Outline daily plan; discharge estimate • Summarise plan for the day and assign responsibility • Propose plan for discharge • Provide Estimated Date of Discharge (EDD)

1) Venous thromboembolism. Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis.

Source: Orange Health Service, NSW, Australia; Clinical Excellence Commission, NSW, Australia; Advisory Board interviews and analysis. SIBR

Purpose: The Complex Disease Case Conference committee shall be responsible for overseeing the identification of suitable members for coordination and initiation of case conferences aimed at developing a comprehensive plan of care to address the individual needs of the member.

Responsibilities include: • Identification of patients appropriate for case conferencing • The scheduling, coordination, and implementation of individualised case conferences • Review of patient medical records • Development of a comprehensive plan of care that is documented via electronic medical record • Promotion of the most efficient use of available resources to ensure timely, quality, coordinated care delivery in the most suitable setting • Identification and referral of potential quality issues • Ensure compliance with organisation and regulatory requirements • Provide timely information to the appropriate provider following case conference • Identify lead doctor for the management of the case discussed

Limits of Authority: The committee may utilise any of the following to carry out its functions: • Form ad hoc sub-committees • Make recommendations on matters related to effective management of the patient’s medical and social issues • Make adjustment to the medication regimen with or without the presence of the primary doctor • Request information from other committees, departments, and/or individual staff members

Frequency of Meetings: This committee may meet as often as necessary to carry out its business but shall meet at least monthly

Source: Kaiser Permanente Southern California Region, Pasadena, CA, US; Advisory Board interviews and analysis.

Voting Rights: All members are voting members

Appointment of Members and Term of Office: Doctor members will be appointed by the chief of service. There is no term limit for members of the committee.

Membership Composition: • Facilitator (utilisation management/quality management chair, hospitalist) • Hospitalist • Nephrologist • Cardiologist • Primary care • Case managers (hospital, heart failure, ESRD1) • Continuing care (palliative, hospice, home health) • Social services • Quality • Pharmacy • Emergency department/Urgent care Ad hoc: Department administrators, pulmonologist, bioethicist, other MDs

1) End stage renal disease. Source: Kaiser Permanente Southern California Region, Pasadena, CA, US; Advisory Board interviews and analysis.

Agenda

Discussion Topics Duration

Review current system data: High-risk patient reports, trended readmission rates and counts 5 min

Review existing action plan and case log (e.g., number of days since last readmission) 10 min

Case #1: Overview of case, GP perspective, care plan, next steps 20 min

Case #2: Overview of case, GP perspective, care plan, next steps 20 min

Wrap-up: Update action plan 5 min

Source: Kaiser Permanente Southern California Region, Pasadena, CA, US; Advisory Board interviews and analysis.

Source: Abington Memorial Hospital, Abington, PA, US; Advisory Board interviews and analysis. Abington’s Abington’s

Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis. The Ottawa’s Personal Decision Guide Personal Ottawa’s The

Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis. The Ottawa’s Personal Decision Personal Ottawa’s The

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1) Ottawa Hospital Research Institute. Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis. Advance Care Planni Care Advance OHRI Through Available

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1) Ottawa Hospital Research Institute. Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis. Advance Care Planni Care Advance OHRI Through Available

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1) Ottawa Hospital Research Institute. Source: The Ottawa Hospital Research Institute, Ontario, Canada; Advisory Board interviews and analysis. Advance Care Planni Care Advance OHRI Through Available

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