EXECUTION

October 24, 2014

Real Time Demand Capacity (RTDC) Approach

Identify

Barriers to

Accomplishing

Plans

Focused

Improvements

on Barriers

Real-Time

Matching of

Capacity to

Demand

Shift/Add

Capacity to

Address Large

Mismatches

Copyright © 2013 Institute for Healthcare Improvement

Months: 3 6 9 12 24

. . . .

Larger

Improvement

Projects . . . .

Execution \Ex`e*cu"tion\, n

The act of doing something successfully; using knowledge as distinguished from merely possessing it

Source: Webster's Revised Unabridged Dictionary

By Definition

Objectives

Share some thoughts on disciplines that can

assist in execution

Increase your ability to make improvements in

patient flow

Execution:

A Portfolio of Disciplines

1. Testing and implementation

2. Project management

3. Change management

Testing - trying and adapting ideas to learn what

works in your system

Implementation - making a change a permanent

part of the day to day operation of the system

Testing versus Implementation

Testing to Implementation:Multiple Plan-Do-Study-Act (PDSA) Cycles

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Small Scale Test

Follow-up Tests

Wide-Scale Tests

Implementation

of Change

A P

S D

A P

S D

A Few Tips for Testing

Scale down the size of the initial test of a change (# of patients, staff, units, time period). Learn from any failed tests.

Use multiple PDSA cycles to increase the scale and test over a wider range of conditions.

Set a good tempo for testing

Small scale = Small change

Implementation Strategies to Hold the Gains: A Checklist

Document the standard process and audit it periodically

Make changes to job descriptions as necessary

Assign ownership

Use measurement over time

10

UPMC: Some Standards for RTDC

Daily (M-F) unit bed huddles are required prior to bed meeting

Daily (M-F) bed meeting is mandatory

Each unit is required to submit a prediction sheet (RTDC Management Form) daily; predictions & plans must be documented in writing on the prediction sheet

After the meeting, discharges (potential & confirmed) must be reconciled every 2 hrs minimum by the unit secretary

Nursing leadership presence is required at each bed meeting

Evaluating Results

Note from a Flow Team on the results of

their work:

We improved our “ED LOS for admitted patients”

from 5.1 hours in July to 4.5 hours in August.

Time Series Design

Mar Apr May June July Aug

5.15.2

5.0

4.8

4.6

4.4

4.2

4.5

ED LOS (hrs) for Admitted Patients

13

UPMC Shadyside:

Median ED LOS for Admitted Patients

Execution:

A Portfolio of Disciplines

1.Testing and implementation

2. Project management

3. Change management

Hope is not a plan….

neither is

If only we could….

Some Suggestions on Managing a Project

Designate a Day-to-Day Leader (Project Manager)

Document the work plan: who, what, by when

(Set tempo: 30-60-90 day cycles)

17

To DoWorking

WellPlan (activities and tests -include

who and what)

By

When

1. Start a discharge list by

unit each day

- Flow Team to develop a format for

discharge list and discuss the proposed

process with 3South and 4North

- Kathy to oversee tests of list

11/14

11/17

2. Establish a daily Unit

Bed Huddle to finalize the

discharge list

3. Provide daily feedback

on actual discharges

Step #1: Predict Capacity (available beds plus discharges by unit)

RTDC Work Plan

Some Suggestions on Managing a Project

Designate a Day-to-Day Leader (Project Manager)

Document the work plan: who, what, by when

(Set tempo: 30-60-90 day cycles)

Create a review process to understand if “what,

by when” happened

Keep focused on the goals

Execution:

A Portfolio of Disciplines

1. Testing and implementation

2. Project management

3. Change management

Addressing the people side of change

Prochaska’s Stages of Change

Pre-contemplation

Contemplation

Decision

**Action

Maintenance

Selling an Idea

Needed:

1. A volunteer with a good idea

2. A group of potential adopters

Attributes of an Idea that Facilitate Adoption

Relative Advantage

Simple Trialable Compatible Observable

Adopter Categories

Innovators

Early

Adopters

Early

Majority

Late

Majority

Laggards

2.5% 13.5% 34% 34% 16%

Source: Rogers, 1995

UPMC Mercy

The People Side of Change

The Balancing Act

How do we Engage Staff?

Deliver the message at every possible forum

- not only the how but the why

Shared Governance Committees

Ancillary Department staff meetings

Charge Nurse orientation classes

Resident noon conference

Grand Rounds

Executive Leadership Meetings

How do we Engage Staff?

Establish “what’s in it for me”

Charge RN….as the “Air Traffic Controller” you have a clear map, focused work

Patient Placement….no longer the burden to manage the entire house

ED RN…no longer the need to board patients for extended time

Evening staff RN….no longer the 3 - 7 crunch of 10 patients out & 10 patients in

Daylight staff RN….I’ll be that evening staff nurse soon

How do we Engage Staff?

Show staff that administratively you are supporting them

Provide easy escalation routes when they run into barriers

Put a face to their escalation path

Senior Leadership presence at the Bed Meetings

Leadership presence intermittently at Unit Huddles

How do we Engage Staff?

Give staff daily feedback & recognitionDaily results, what went well yesterday – where are our opportunities

Never create a punitive environment

Give monthly achievement awards, no matter how small

Pizza, bagels, Chex mix, chocolate all work!!

There will be those days….be there for them

Engage the early adoptersCreate apostles & take them on the road

Maintaining Momentum

• As a leader, don’t lose your focus

• Report consistent results/metrics

• Show the effects of work house-wide

• Positive feedback from senior leadership

• Keep the next goal always on the horizon and

visible

Going from Good to Great

Will

Ideas

Execution

References

Berwick D. A primer on leading the improvement of systems. BMJ

1996; 312: 619-622.

Cook T, Campbell D. Quasi-Experimentation. (Boston: Houghton Mifflin

1979)

Langley J, Moen, R, Nolan K, Nolan T, Norman, C, Provost L. The

Improvement Guide. 2nd Edition (San Francisco: Jossey-Bass 2009)

Tufte, E., The Visual Display of Quantitative Information, (Cheshire,

CT:Graphics Press,1983)

References

Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.

Block, P. Flawless Consulting: A Guide to Getting Your Expertise Used. 2nd Edition, Hoboken, NJ: Wiley Inc., 1999.

Heifetz, R. Leadership without Easy Answers.Cambridge, MA: Harvard Press, 1994.

Kotler P., Roberto E. Social Marketing: Strategies for Changing Public Behavior. New York, NY: Free Press, 1989.

Prochaska J., Norcross J. Diclemente C. In Search of How People Change, American Psychologist. September, 1992.

Rogers, E. Diffusion of Innovations. New York, NY: The Free Press, 1995.