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24/7 Care Delivery Models
Research Project
UHC / RAND Collaboration
Joanne Cuny RN, BSN, MBA
Quality & Risk Councils Meeting
Director of Quality
February 19 – 20, 2009
2009 University HealthSystem Consortium UHC/RAND Received AHRQ ACTION Grant to
Examine 24x7 Care Delivery Models
 AHRQ “Accelerating Change and Transformation in Organizations and Networks (ACTION)" grant awarded to UHC and RAND Corp to support  The study evaluated strategies designed to reduce workload demand on medical and surgical service teams in academic medical centers; and then reallocate staffing supply to match that demand around the clock. Key areas of inquiry included: How does staffing supply and demand vary around the clock? What interventions are effective in minimizing demand? What workforce strategies best fit with optimal demand? What are the consequences of care redesign on clinical quality? Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium A Quasi-experimental Study Model
 Steering Committee consultation on scope and design Study site recruitment and group assignment  Demand and supply intervention design (best practice details)  Sites participate in implementation collaborative  Pre-implementation (baseline) data capture  Participation in improvement collaborative - Gap analysis (current state vs best practices) *Commit to ACTion
Data capture to measure compliance to plan Analyze data and evaluate plan effectiveness *UHC’s rapid cycle
improvement collaborative
 Maintain system change for duration of study methodology
 Analysis of performance measures data  Formative evaluation of implementation model Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Study Design
Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Participating Organizations
(# of pilot units)
Study Arms:
Intervention Arm 1: Demand only
University of Maryland Medical Center (4)
University of Florida-Shands HealthCare (2)

University Hospitals Case Medical Center (1)
Medical College of Georgia Health (3)
Intervention Arm 2: Demand plus Supply

West Virginia University Hospitals (3)
University of Kentucky Hospital (1)

Mount Sinai Medical Center (2)
Stony Brook University Medical Center (2)
Northwestern Memorial Hospital (1)

New York-Presbyterian Hospital – Columbia (2)
Comparison Arm 3

Emory Crawford Long (2)
University of Iowa Hospitals & Clinics (2)
UMass Memorial Medical Center (2)

15 UHC hospitals
The Methodist Hospital (2)
30 pilot units
Rush University Medical Center (1)
Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Demand Intervention:
Discharge Planning
GOAL: Improve patient flow and throughput
 Ensure integrated communication across disciplines  Review and discuss plan for care and discharge with patient  Confirm patient disposition and, if appropriate, complete discharge  Determine tasks to be accomplished and assign responsibility Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Demand Intervention:
Structured Handoffs
GOAL: Improve quality and safety of patient care
 Standardize information to be included in every handoff  Protocol followed when patient moves and when staff changes  Mandated use of the handoff form for study  Ensure integrated process across disciplines, with handoff report  Handoffs to be scheduled at a regular time and place  Identify a location where interruptions and distractions are limited Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Demand Intervention:
Managed Paging Process
GOAL: Minimize service team distractions from patient care
 Determine a signal to indicate level of urgency for response:  Assign responsibility to triage pages for urgency level to senior  Cluster delivery of non-emergent/urgent pages to scheduled  Consider eliminating pages for information only by implementing message boards/clipboards/notebooks on units or utilizing e-mail (must establish method to determine message received) Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Demand Intervention:
Common Complaint PRN Order Sets
GOAL: Eliminate interruptions in patient care to order
medications to relieve symptoms that are common to
hospitalized patients

 Develop a common complaints order set to include as needed  Headache or mild pain (e.g. acetaminophen)  Mandate the use of the common complaints order set unless Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Supply Intervention:
Matching Supply to Demand
GOAL: Match supply to demand around-the-clock
 Determine hourly workload demand (Staffing Planner)  Study the hours of activity demand related to admissions and discharges for the pilot unit (Activity Curves)  Review staffing profile (available service team members)  Evaluate current care delivery team competencies relative to  Create a staffing schedule, moving human resources with appropriate competencies to cover the observed demand Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Comparison Arm
 Matched to geographic location and Case Mix Index (CMI) Each site identified medical and/or surgical pilot units Provided the same data elements collected from interventional sites from the time period identified as  Participated in Formative Evaluation telephone interviews Without the interventions, changes noted in comparison site outcomes should indicate secular trends Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Research Questions
A. Primary Research Questions:
Does implementing the redesign intervention improve EFFICIENCY
What are the consequences of implementing the system redesign strategies
on CLINICAL QUALITY?
B. Secondary Research Questions:
How does EFFICIENCY differ in demand-only intervention hospitals
compared to demand & supply intervention hospitals?
How do the consequences on CLINICAL QUALITY differ in demand-only
intervention hospitals as compared to demand & supply intervention How is the BUSINESS CASE different in the demand-only intervention
hospitals as compared with demand & supply intervention hospitals?
How do the consequences on PROVIDER JOB SATISFACTION differ in the
demand-only intervention hospitals as compared to the demand and supply Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Hypotheses Related to Primary
Research Questions
System redesign by full implementation of study interventions will:
EFFICIENCY outcomes
Move average discharge time to earlier in the day CLINICAL QUALITY outcomes
Have no ill-effects on glycemic control or # of PSIs Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium Questions?
Please share your experiences
with 24/7 care delivery models
Quality/Risk Council Meeting, February 2009 2009 University HealthSystem Consortium

Source: https://www.ukhc.uky.edu/ldp/2010/afterhourscoverage/Shared%20Documents/003733176_CunyQualityRiskMtgFeb09-1.pdf

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