Demand management helps reduce diverts
Best practices diffused across the system
A demand management program created at Overlook Hospital in Summit, NJ, has successfully reduced diverts, thus leading to an 89% staff retention rate. The program has been implemented across the four-hospital Atlantic Health System, of which Overlook is a member.
"While everyone else was going on divert, our last full divert was February 4th, but before that, we had gone 761 days without a divert," reports Linda Kosnik, RN, MSN CSCEN, chief nursing officer. In addition, the average admission cycle time was reduced from 129 minutes in April 2001 to 78 minutes in October 2001.
The need for such a program was spurred by the extraordinarily long times for admission in the Overlook emergency department (ED), Kosnik recalls. "We had recruitment and retention issues because we were holding patients in the ED," she explains. "Our goal was to reduce divert and bypass, which I believe is a result of inpatient services meltdown. We determined to reduce waits and delays using a crew resource management (CRM) approach."
CRM, she explains, is a communication methodology focusing on team-centered decision-making systems, which was developed by the aviation industry. The concept originated in 1979, in response to a National Aeronautics and Space Administration workshop that examined the role that human error plays in air crashes. When CRM is applied to health care, the communication dynamic of health care practitioners caring for critically ill patients can be viewed as resembling that of an aircrew engaged in complex flight operations. Use of team-centered decision-making systems enables teams to perform more efficiently.
Major goals established
As well as those goals, Kosnik and her team set forth these additional targets:
- Drive the diffusion of best practices.
- Decrease variation.
- Create a safe environment for patients and staff.
- Improve customer satisfaction.
- Improve communication.
- Apply an integrated approach to resource management.
This latter goal was virtually assured by the size and diversity of the team. In addition to such obvious members as the ED and inpatient and outpatient services, it included 22 support services. "These are frequently overlooked, yet they are probably the most important," Kosnik notes. "They don’t realize how much they impact on the ability of patients to move through the system."
The best way to illustrate this, she says, is to imagine a single patient in the hospital, whose physician is waiting for labs to discharge him. "If the labs are not ready, discharge is deferred until the doctor has another time [to] review them," Kosnik explains. "That can be almost a day. An individual who could be discharged continues to occupy a bed, and that starts to snowball. People in the lab had no idea that was happening," she says.
The team members gained greater understanding of their interdependence as the process unfolded, in part because of the structure itself. The program used color-coded "states" to illustrate the status of a given department or service. Green indicated a good day, based on criteria and interventions for that system. Yellow, orange, and red represented progressively less-desirable states. "We initially identified what was perceived as a good day in terms of such issues as budgeted capacity," Kosnik explains. "The team added things in. For example, although respiratory therapy is budgeted for 100 [interventions] a day, the team realized that if they had 100 a day, staff might have to be cancelled."
The interventions were determined by the respective departments. "No one else could tell them what the early triggers, good days, and interventions are," Kosnik says. Since this process was conducted systemwide, it also allowed a sharing of best practices. "The team members might have been doing certain things for years, but they had not told anyone," Kosnik notes.
An intertwined web
In the team structure, every service or unit has a partner, and they are the ones responsible for seeing that the unit is in green, Kosnik explains. So, for example, environmental was partnered with dietary, because it was found that dietary would be brought back to green if someone else picked up the dirty trays. "If they were 10 minutes later with one tray delivery, by the end of the day, that delay was compounded," Kosnik says. "It was a satisfaction issue. People who came to visit patients were affected, and people were discharged who were still struggling to keep their meal down. Dietary had no idea of its impact on the way the system moved."
A hospital or a system is an intertwined web, Kosnik continues. "It’s always one system that goes down first," she explains. "The first thing that occurs, you intervene. For example, in the neuro unit, one of the biggest triggers is feeders. They don’t have adequate staff. Their partner is respiratory, which is located right next to them. If neurology identifies themselves as being in yellow because of feedings, respiratory will send a tech in for a couple of hours."
Kosnik views a hospital or system as a metaphor for the human body. For example, if the liver is not doing what it is supposed to do, it will compromise other organs. "But other organs will try to take over," she points out. In the hospital model, patient transport often fails first. Therefore, the numbers for their green and yellow states are much lower than they are for other departments. "If you can’t get patients to services, everything starts to snowball," Kosnik explains.
That’s why it’s important to have automatic interventions built into the system. "The closer you get to red, the more interventions you need to get back to green," Kosnik observes, "You need more resources. So you must make every effort not to get there. And that, in turn, creates a lot of collaboration between units." Which, quite naturally, enhances communication and cooperation. "It’s real hard being angry with someone who you depend on," Kosnik says.
For more information contact: Linda Kosnik, RN, MSN, CS, Chief Nursing Officer, Overlook Hospital, 99 Beauvoir Ave., Summit, NJ 07902. Telephone: (908) 522-2095.
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