The results are in!

Data from the Accountable Care Unit (ACU) pilot project has been compiled and the results show that health care transformation is indeed possible through this model of care.

During the first six months after ACU implementation on Unit 4A at the Pasqua Hospital, we observed large and significant improvements across a range of outcome and process measures that affect both patients and staff.

Some key indicators include:

Patients are going home sooner. Length of stay at the hospital was 18.84 per cent shorter than that on our comparative medicine unit.  Unit 4A was able to increase the number of patients flowing through the hospital system, and helped decrease patient pressures elsewhere.

Patients are happier with their care. The unit saw a 72.98 per cent decrease in complaints lodged to the patient advocate compared to pre-pilot. In general, patients were happier with their care and many issues were able to be resolved at the bedside.

Staff are more engaged in their work. Compared to pre-pilot data, employee engagement surveys showed a 22.40 per cent increase in how staff relate to their supervisors.  Employees are active participants in metrics reporting and implementing change on the unit to make things better every day.

Patient safety is improved. Two big risks when being admitted to hospital are 1) the risk of internal bleeding; and 2) the risk of an embolism (which develops when your blood clots and gets stuck in smaller blood vessels.) To combat these risks, VTE Prophylaxis (drugs that thin your blood), may or may not be administered to patients, depending if they fall into the first or second category. On the ACU, the rationale for VTE Prophylaxis was documented 39.44 per cent more often if it was not required. This increases patient safety, and ensures that an important step in patient care is not overlooked.

Patients are leaving the hospital healthier. As a result of the More 2 Eat study conducted on the unit, malnutrition screening has increased 13.54 per cent and the patient weights were more frequently documented in their charts (185.61 per cent increase), helping dietitians intervene sooner.

RQHR’s Senior Leadership Team has provided their full support for the report, which will be released online in early 2017. In addition, the Senior Leadership Team has confirmed that Units 4A and MSU at Pasqua will continue to operate as Accountable Care Units.

What are staff and physicians saying about the unit? Watch this video.

What is an Accountable Care Unit?
It is a system of care in which care team members are better connected with one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible.

The Regina Qu’Appelle Health Region’s Accountable Care Unit (ACU) pilot project is a key strategy for the region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. This pilot project was made possible through funding from the Ministry of Health and additional funding from the region.

What is an Accountable Care Unit? It is a system of care in which care team members are better connected with one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible.

The Regina Qu’Appelle Health Region’s Accountable Care Unit (ACU) pilot project is a key strategy for the Region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. The Region’s Senior Leadership Team believes that the pilot will successfully demonstrate that we can transform our care system for all our acute inpatient units. This pilot project is made possible through funding from the Ministry of Health and additional funding from the Region.

The six month pilot ended on August 24th, 2016, so this project is now in a transition phase. The established structure and processes will continue until November 30th, 2016. From now until then, in addition to continuing all ACU processes, robust evaluation will be occurring as part of the research component of the project and analysis of outcomes will be presented to RQHR’s Senior Leadership Team to determine replication options.

On an ACU, shared routines are foundational to creating high performing teams. The daily routines being applied on 4A are: Structured Interdisciplinary Bedside Rounds (SIBR), Team Huddle, Shift to shift bedside handover (now known as Transfer of Accountability) and Debriefs.  The debrief sessions are a 10 minute team discussion, focusing on unit-based metrics four days a week and on learning needs of the unit two days a week. These valuable debrief sessions enable staff engagement and feedback in real time and are a sign of the continuous improvement culture that has been created through their journey in implementing an ACU.

New patient whiteboards have now been installed in all patient rooms. The whiteboards are an integral tool that supports and facilitates communication between the care team, the patient and their family. To ensure boards are updated consistently, standards for use of the boards have been built, including communication related to the More2Eat study. As with all the other changes that have been implemented so far, this process will be monitored, evaluated and adjusted as needed, based on feedback from the frontline staff.

Prior to many of the changes, the team spent a significant amount of time defining the Charge Nurse role, which aims to facilitate patient flow on the unit. One of the key roles of the Charge Nurse is that of Rounds Manger during SIBR. The Rounds Manager facilitates the flow of SIBR and ensures that the team stays on time, organizes and prepares the team nurses for SIBR, and updates Sunrise Clinical Manager software with the target date of discharge in real time for the team. The work surrounding the charge nurse role started in May and is ongoing.

With the departure of the Clinical Nurse Educator (CNE) and Clinical Resource Nurse (CRN), Manager Sheri Bray has taken on extra responsibilities to continue the education, implementation and evaluation of all the above processes. In August, the new CRN and CNE were hired and will start learning about the ACU and how it functions on 4A to gain a better understanding of their role in supporting the staff in this model of care.

Over the next couple of months, the team on 4A will continue to embed the new and existing processes on the unit and continue sustaining the improvements that have been observed. A process for SIBR certification is in development and aims to be in place by October 2016. This certification gives nurses and physicians a way to demonstrate excellence in transforming something complex into something routine-leading and co-ordinating an interdisciplinary team at the bedside. It also gives leaders, managers and educators a reliable way to affirm demonstrated competence.

Patients are saying:

‘The staff on 4A were amazing!!! Very attentive, always asking how I was. They made the stay very easy and explained things any time I had questions. I came up here after very hard circumstances and they made the stay enjoyable and provided the knowledge I needed to carry on with my treatments after leaving the hospital.  I received amazing care and I am very thankful for that.’  - 4A Patient

‘The team rounds were great. We didn’t have to wonder where the doctor was. We were better informed on a regular basis than on any previous stay.’ - 4A Patient

Staff are saying:

‘After recently spending a day observing the Accountable Care unit at the Pasqua Hospital, I wasn’t disappointed. There is clearly a high level of staff morale and engagement, as well as patient satisfaction. Relationships between the entire interdisciplinary team are collaborative and respectful. The communication and teamwork is fascinating. It’s truly a magnet-like environment.’  - KOT Specialist, Medicine Service Line

Physicians are saying:

‘I come across Canada to work in the ACU simply because I can’t do ‘this’ anywhere else’ – 4A Hospitalist

Dr. David McCutcheon, Vice President, Physician and Integrated Health Services

What is an Accountable Care Unit? It is a system of care in which care team members are better connected with one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible.

The Regina Qu’Appelle Health Region’s Accountable Care Unit (ACU) pilot project is a key strategy for the Region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. The Region’s Senior Leadership Team believes that the pilot will successfully demonstrate that we can transform our care system for all our acute inpatient units. This pilot project is made possible through funding from the Ministry of Health and additional funding from the Region.

In any improvement initiative, the working group must always be able to monitor how the implementation of the project is doing. Are there any areas that need to improve? How will you know if the changes are really resulting in improvements? To understand if your changes truly are making an improvement, you require tracking data and metrics. There are a variety of metrics being collected to show the impact of the ACU pilot.

The decision to support an ACU is based on initial research by Dr. Jason Stein which was published in New England Journal of Medicine (NEJM) in 2014 that identifies the following outcomes: improved staff and physician satisfaction, enhanced patient care and satisfaction, decreased length of stay, safer care manifested by reduced morbidity and mortality and cost savings. Early observations on 4A have identified significant improvements in the quality of patient satisfaction as well as improved staff and physician engagement. To support our confidence in the outcomes of this pilot and for future decision-making, we are conducting formal research that will help quantify the outcomes achieved.
This month, we would like to continue to highlight an important metric that contributes to the pilot’s overall assessment: Patient length of stay (LOS).

The traditional health care model can have physicians distributed throughout multiple hospital units and hospitals. This practice can create an environment where physicians are required to travel between units daily, providing them with less time for each patient and decreased availability for the care teams. Staff on 4A found this model challenging as they had less time to communicate with the physician about the patient’s plan of care, resulting in fragmented communication and a challenge for consistency of care, at times resulting in extended length of stay for the patient. The transformation that ACU has brought to 4A has created an environment where a team of physicians work on one designated unit with a designated care team. This shift from the traditional design has enabled cohesiveness, communication, timeliness and face to face problem solving. Based on the previous research conducted by Dr. Stein, the ACU model had a significant impact on patient care and a length of stay reduction was observed. Based on the same referral volumes, the length of stay at Emory University Hospital in Atlanta Georgia reduced from 5.0 days to 4.5 days—a 10% length of stay reduction which the ACU team hopes to achieve after the six month pilot has been completed. The reduction in length of stay will, in turn, positively impact patient flow within RQHR, allowing for faster turnover of beds and movement from the ER into acute inpatient beds and discharges out into the community.

Another major impact on the patient’s length of stay pertains to the patient’s dietary intake and malnutrition. Food is medicine. Data indicates that patients who consume 50% or less of their meal tray will have a longer hospital stay and increased risk of mortality.

The More 2 Eat study is being conducted on 4A to improve the detection and standard treatment for malnutrition in hospitalized patients. The RQHR was selected as one of five locations in Canada to participate in the 18 month study, an initiative to improve nutrition care. This is of particular importance in our Region, as preliminary studies identified that as many as 60% of patients are malnourished upon admission. Nutrition care involves everyone from the Physician, Nurse, Dietitian, Pharmacist, Food Service Worker, Unit Clerk and many more. The first step of the pathway is to identify patients at nutrition risk. A nutrition screen (2 simple questions) has been added as part of the nursing admission database and to date is being completed over 80% of the time.

One process that supports best practice is a standard nutrition screening that is being completed by the nursing team on admission for all patients on 4A. An automatic dietitian consultation is completed for patients identified as being at risk for malnutrition based on the finding from the nutrition screening. A key indicator of malnutrition is based on assessment of food intake. In order to get an accurate assessment of the patient’s food intake, patient whiteboards are being used to communicate food consumption at every mealtime. Dietitians use this information to assist in the patient’s care plan.

Patients are saying:

“I dearly hope this program is continued as it is a huge improvement in health care. I feel better looked after and am healthier when I left this program. The nurses and doctors were happy, and worked well with one another. The care was top drawer. The health care in our system needs revamping and this program, that I have been a patient in, is a win for everyone.”

Staff are saying:

“We are able to keep on top of things because everyone’s involved with the patient more regularly all together, we all know what the other person is thinking.” – RN on 4A
“We cannot go back to the way it was before this pilot started.” – RN on 4A

Physicians are saying:

“I really enjoy the regiment of the unit, and having the other health care team members present every day to help me steer the patient through their journey. Every unit has their own way of doing things, and so it can take almost your entire time learning how a particular hospital ward functions, only to be moved to the next ward the week following. With the ACU, you can learn the ward routine in a few days and be supported by the other health professions daily. This also means that if I have questions for my mentoring physician, I know where they are and I know what their routine is. Hence, the environment is more conducive to learning.” –Resident Physician

For more information on the Accountable Care Unit pilot project, please visit our website: http://www.rqhealth.ca/clinical-support/accountable-care-unit.

Dr. David McCutcheon, Vice President, Physician and Integrated Health Services

Accountable Care Unit pilot project

Research is a critical component of the Accountable Care Unit Pilot Project.  This month, we’d like to highlight two important metrics contributing to the pilot’s overall assessment: patient and staff satisfaction surveys.

Patient Satisfaction

In traditional hospital care, Patients and families are not consistently involved in their care plan.  When patients and families have questions, care providers cannot always address the questions in a timely manner as the team works in a fragmented environment. Regularly, families miss the opportunity to meet with the physician caring for their family member. These and other contributing factors traditionally result in patient and family complaints.

The ACU processes such as Shift to Shift bedside handover and Structured Interdisciplinary Bedside Rounds (SIBR) have been structured to ensure the patients and families are present and engaged in their care.  This process change has enabled patients and families to directly communicate with their care team allowing for better communication with the entire care team and ensuring accountability of care. 

To evaluate the changes, a patient satisfaction survey initiated by the Kaizen Promotion Office is distributed to all patients on discharge and patient and family complaints will also be measured.

This data will be collated and presented to show the gains of the patient and staff satisfaction
resulting from the implementation of the ACU model on 4A.

Patients are saying:
“Excellent care by nurses and doctors, very pleased with the level of care and high standards by all staff.”
“We liked the team approach to care.”
 “Keep up the good work. You made the most unpleasant experience as pleasurable as you can make it.”

Staff Satisfaction

In traditional hospital care there can be communication breakdowns with other disciplines and staff spending some of their day hunting for patient information that they required in order to carry out the appropriate care plan for the patient. As a result, it can be challenging for all disciplines to build effective relationships with each other as patients have been placed throughout the hospital, not just based on one unit.  This was one factor that previously left 4A staff feeling frustrated with not enough time to complete all tasks or be at the bedside for their patients and not being able to provide patients and families with needed information about their care. 

One desired outcome of an ACU is that each staff member feels cared for, supported and respected.  One way this is achieved is through the implementation of Structure Interdisciplinary Bedside Rounds (SIBR) that assists in creating relationships based on mutual respect and cohesiveness amongst the interdisciplinary team, allowing for open communication.  An ACU is designed as a geographical unit, with patients and care providers on one unit allowing the opportunity to share time and space throughout a shift. This home unit creates predictability, giving the care providers the chance to create strong relationships based on trust, respect and provides an environment to practice seamless consistent routines.  4A staff are engaged by contributing to the development of all the tools and methods being trialled and sustained on the unit and having the opportunity to provide feedback on the changes. Improving employee engagement has a positive impact on staff satisfaction and results in improved patient care and greater patient satisfaction.

To evaluate the changes, 4A is capturing staff satisfaction surveys to measure the moral on the unit post implementation in conjunction with measuring sick time to see if there is a correlation.

Staff are saying:
“The changes that have taken place on 4A are great.  They are great for nurses, doctors and patients. Now we are investing more time in patient care rather than spending time phoning doctors on shift.”- RN 4A

“I feel like the patients and the families have the ability to be more present in their families care and give us more valuable information.  It definitely has affected families, allowing them to be more included in their care.” – Assessor Coordinator
 “I am really scared to go back if it goes back to the regular ways because I think this just makes so much sense. This is how it should be done.  Running around wasting time not being at the bedside putting people in danger, making them feel insignificant is ridiculous.” – RN 4A

Physicians  are saying:
“I can honestly say that the type of care that we’re providing, the feedback we’re getting, the value we’re providing, it is exactly the reasons why I went into medicine.  This is feel good medicine at its best.”  -4A Hospitalist

What is an Accountable Care Unit? It is a system of care in which care team members are better connected with one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible.

The Regina Qu’Appelle Health Region’s Accountable Care Unit pilot project is a key strategy for the Region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. The Region’s Senior Leadership Team believes that the pilot will successfully demonstrate that we can transform our care system for all our acute inpatient units. This pilot project is made possible through funding from the Ministry of Health and additional funding from the Region.

Over the past two months, the unit-based management team of Dr. Ron Taylor and Sheri Bray, RN, have continued to provide leadership and define the process of the Accountable Care Unit (ACU) on unit 4A at the Pasqua Hospital, where the ACU is being piloted. One of the foundational elements of the ACU places all patients on the unit under the care of the hospitalists, which began at the end of February and allowed the unit to function fully as an ACU.

Structured Interdisciplinary Bedside Rounds (SIBR) continues to occur 7 days a week, with the entire care team, which include the pharmacist, social worker, nurse and physician, all of whom share and confirm information about the patient’s plan of care with the patient and family.

One process that takes place before SIBR and helps prepare the team with the needed information and planning is Shift to Shift hand over. Shift to Shift hand over is a routine that enables each on-coming nurse to start the shift with the information needed to prepare for SIBR and to verify everything reported from their off-going colleague at the bedside with the patient. 

The unit is currently trialing a new whiteboard in a patient’s room and incorporating its utilization into SIBR and Shift to Shift handover. Patient whiteboards are a tool to improve teamwork and communication between members of the care team and engage patients in their care. 

Patient satisfaction survey results are one of the key evaluation metrics for this pilot, and thus, patient satisfaction surveys, have been administered to patients since early February.

Patients are saying:

"Kind and considerate health care givers. Knowledgeable, answered questions and ensured that follow-up procedures are in place." 4A Patient.

"Nursing staff were very professional and always took the time needed to ensure my Mom was okay. Compassion has not been sacrificed for efficiency." A child on behalf of their parent.

Staff are saying:

"This Accountable Care Unit has made me love nursing again." LPN on 4A.

With the early successes of the pilot, we also recognize there have been challenges.  Feedback has been provided that has resulted in adjustments.  This feedback is welcomed and a valuable component of the assessment of the pilot.

In the next month, there will be continued refinement of the ACU process including SIBR, shift to shift handover and incorporating the patient’s whiteboard into the new model of care. One of the key components of an ACU is unit-based metrics.  Currently, there is an emphasis on Immunization rates of patients – specifically flu and pneumonia.  The formal research components are focusing on patient flow and there is ongoing evaluation of the hospitalist-only unit.

What is an Accountable Care Unit? It is a system of care in which care team members are better connected with one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible.

The Regina Qu’Appelle Health Region’s Accountable Care Unit pilot project is a key strategy for the Region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. The Region’s Senior Leadership Team believes that the pilot will successfully demonstrate that we can transform our care system for all our acute inpatient units. This pilot project is made possible through funding from the Ministry of Health and additional funding from the Region.

 
Dawn Calder, Acting Vice-President, Integrated Health Services
Dr. David McCutcheon, Vice President, Physicians and Integrated Health Services

co-chairs, Accountable Care Unit pilot project

Since the January 15 kick-off of the Accountable Care Unit (ACU) pilot on Pasqua Hospital’s Unit 4A, there has been significant progress in the foundational components of an ACU.  One of these components is structured interdisciplinary bedside rounds (SIBR), where the care team, consisting of  four or more members in size, travel from patient room to patient room and share information about the patient’s plan of care, while revising as necessary. The plan is shared with each other and most importantly, with the full participation of the patient and family. Staff are also using a new way to improve nurse to nurse communication during report at shift handover by using a standardized handover communication tool at the patient’s bedside. These components are subject to ongoing monitoring and evaluation.

The research evaluation component is well underway with the pre-intervention data collection and analysis continuing and development of a unit-specific dashboard with both clinical and operational outcome and process measures.

The unit based management team of Dr Ron Taylor and Sherilyn Bray are performing well and leading the development, with excellent support from the Oversight Committee.

At the kick-off event last month, staff and physicians signed their unit covenant, in which staff promise to uphold their covenant values.  This covenant will be displayed on the unit and serves as a daily reminder to all staff and physicians of their commitment to the project and its new work culture.

As with any change initiative, there are challenges to work through; however the team members continue to receive positive feedback from those involved in the project. Here are some examples:

Nursing staff members are saying:
"For the first time I feel I have contributed to and understand the plan of care for my patient", RN on 4A

Physicians are saying:
"We can already see how this model will improve patient care and our overall work day", 4A Hospitalist

What patients are saying:
"It was good to see patients are number one", 4A Patient 

During the next month 4A will become a hospitalist unit, which means patients will be cared for exclusively by hospital-based physicians. Those patients whose family doctors agree will be admitted to the hospitalist and discharged to their family doctor.

There will be more staff education and specific ACU education will be incorporated in the orientation for new staff.

A prototype of an enhanced patient whiteboard will be trialed and evaluated to ensure this tool meets the needs of patients and families and team members involved in their patient’s care.

What is an Accountable Care Unit?  It is a system of care in which care team members are better connected with one another, and are responsible to each other to ensure that patients receive the safest, highest quality care possible. The Regina Qu’Appelle Health Region’s Accountable Care Unit pilot project is a key strategy for the Region this year; one that aligns completely with our three goals of improving the quality and safety of our care; enhancing patient flow through our system and contributing to a sustainable future. The Region’s Senior Leadership Team believes that the pilot will successfully demonstrate that we can transform our care system for all our acute inpatient units. This pilot project is made possible through funding from the Ministry of Health and additional funding from the Region.
For more information, please visit the Accountable Care Unit page.

 **Please Note: The Accountable Care Unit has opted not to provide an update on this pilot project for the month of March, so as to be respectful of the provincial government’s election writ period. Updates will resume in April.

Starting January 15, Pasqua Hospital’s Unit 4A is going to be the home of a Canadian first.

This will be the site of the Accountable Care Unit pilot project, whose philosophy is that when a team is better connected with one another, patients receive the safest, highest quality care possible. Unit 4A has already begun integrating elements of the Accountable Care model into their care over the past few months, and the ACU operational team has been working hard to prepare for the official launch. This is a true partnership, involving the efforts of (list departments involved), and made possible through funding from the Ministry of Health.

Some changes have already started taking place. Beginning January 15th, 2016, 4A will transition to a pure hospitalist unit and interdisciplinary bedside rounds will be done with all patients on the unit. The 4A staff will continue trialing and adjusting other processes such as bedside shift handover and team huddles.
Understanding the ACU has not yet implemented all the required elements, they are seeing positive effects in how care is delivered and coordinated among the entire care team.

With the early results, team is excited to implement the remaining business processes. Frontline Staff on 4A are actively supporting the development of the standard work, education, tools and check lists that will support improve information sharing and patient care.

In addition to the implementation of the ACU model of care on 4A, formal research is being conducted that will evaluate the effectiveness of this model of care. Patient, Staff and Physician satisfaction will also be assessed as well as tracking key financial metrics.

A significant amount of work has taken place by many people to help make this change possible. Everyone is looking forward to the formal launch of the ACU on January 15th and making 4A a place that provides exceptional care and is a great place to work and learn. During this pilot project, we will continue to share monthly updates on the progress of the ACU on 4A. If you would like more information or have any questions, please email patientflow@rqhealth.ca.