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Accountable Care Unit Pilot
An Accountable Care Unit (ACU) is an inpatient care area structured around four core features. They are: (1) Unit Level Nurse and Physician Co-Leadership, (2) Unit Level Performance Reporting, (3) Structured Interdisciplinary Bedside Rounds (SIBR), and (4) Unit-Based Teams.
Accountable Care Units are the result of work by Dr. Jason Stein, the physician founder of 1Unit. Stein first launched an ACU in 2010 and published his findings in 2014 in the Journal of Hospital Medicine. These findings included improved patient and staff satisfaction, decreased length of stay (10 % reduction) as well as a 50% reduction in mortality as compared to the same ward in the year prior to implementation of an ACU in their 579 bed tertiary academic hospital.
Although not yet published, Dr. Stein reports data from a variety of other sites that have trialed and implemented ACUs in different patient populations and different states and countries demonstrating similar results with length of stay decreases between 10 to 15 per cent and mortality reduction between 30 to 50 per cent. These successes have lead to further ACU models being implemented not only in numerous states in the USA but also in New South Wales, Australia where over 50 units have structured themselves as ACUs.
The four core features attempt to engineer the traits of an effective clinical microsystem. On the surface these features are conceptually simple, but profoundly powerful. At the same time, these features are difficult to implement due to the long standing culture and structure of inpatient units and hospitals that are filled with ‘work-arounds’ and extraneous complexity. Outside of healthcare, and hospitals specifically, these four core features, or the principles they embody, are routine and have been in place in many other industries for years to improve effectiveness while enhancing safety.
John Ash, at the time the Director of Patient Flow for the RQHR, had seen ACUs functioning in Australia and recognized their potential for improving patient flow. An early champion of the ideas, John liaised with nursing leadership on Pasqua Hospital’s Unit 4A and the hospitalists in late 2014 and early 2015 to begin trialing individual features of the concept. Dr. Ron Taylor, section head of the Hospitalists, Erica Pederson, the nurse manager of the unit; Dhon Gumban, the nurse educator, and Amanda Silver, the clinical resource nurse, quickly embraced those ideas they could trial and with the help of the participation of the hospitalists began implementing Structured Interdisciplinary Bedside Rounds, a core element of the ACU model. The 4A staff responded to these leaders and became the backbone of this change. Patients and their families noticed the rapid improvement in communication on the unit via the adoption of SIBR and their positive stories grew.
Bolstered by these early success from the hard work of the 4A staff and hospitalists a proposal for an ACU pilot was approved by the Senior Leadership Team in June of 2015. In September, a small group from 4A including nurse leaders and educators, a hospitalist, social workers, and a pharmacist visited Columbia, South Carolina to visit ACUs and engage with leaders at Palmetto Health as they worked to slowly implement the concepts throughout their hospitals. This was followed by a visit to Regina by Dr. Stein and a group of his colleagues who have implemented ACUs to share their ideas, stories, and insights with 4A and the RQHR.
Much preparatory work has been completed to set up the ACU pilot including: putting research support in place to measure the effects of the pilot, provision of dedicated pharmacists to 4A, recruitment of three additional hospitalists, working with bed allocation and the larger physician community to create a unit-based team with all patients on 4A under the care of two hospitalists.
The pilot is scheduled to begin in mid-January 2016 and to last six months. There remains much work to be done before this start date, but with the buy in, participation, and hard work of the front line staff and the support of leadership and the physician community we hope to demonstrate the same benefits experienced in other hospitals in the first ever ACU in Canada.