The Integrated Operations Center (IOC)

An Operational Environment that supports teams in providing Quality Patient Care

What is our Integrated Operations Centre?

Concept

Place

Purpose

People

What Measurable Outcomes has it had?Acute patient journey - 6 hour target > 90% for 15/19

mnths – a sustained improvement

Cared for 875 more acute patients YTD (4% increase YonY) while maintaining bed utilisation at 2008 levels by a reduction in ALOS, nos. of LOS outliers and improvements in discharge by 11 (using the transit lounge) and weekend discharges

For the three months November to January we have been able to successfully keep closed 44 beds at Tauranga Hospital, and allow more staff to take annual leave over the summer/ school holiday, an have ongoing reduced occupancy

In 2009 – 2011 we had the Perfect Storm..

MOH 6 Hr Target expectations

MOH Safe Staffing Healthy Workplaces – Care Capacity Demand Management trial site

Air New Zealand Integrated Operations Centre visits

What do High Risk and High Performing Orgs have in Common?

And need to Minimise Variance

Variance creates a productivity ‘black hole’Risky! -increases patient risk and

decreases quality of care

Unsatisfactory -stressful and unsatisfactory for staff

Unproductive! -diverts significant resource away from frontline care

Hospitals are High Risk Organisations with Significant Daily Variance at the front door

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Tga ED Presentations Jan-Dec 2010

Added with Growth in Demand..

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2004 2005 2006 2007 2008 2009 2010 2011

ED Attendances (Excl DNW)

TGA

WHK

How do we achieve Safe Quality Care even on a busy day?

Identify causes and address constraints

Minimise and manage variation

Predict demand

Match demand with capacity

Methodology of the IOCOperations Management Principles –

forecasting, planning, demand-capacity matching

Think system-wide, not silo

Visibility of operational status

Data-driven

Yesterday-Today –Tomorrow

Aiming for a Learning Organisation

• Assessing resource requirements• plant• people• supply chain• budget

• People fit for purpose• Working systems• Smoothing variability• Information • Environment fit for

purpose

• Forecasting demand

• Estimating capacity

• Setting organisational goals

• Delivering effective services to patients

• Managing residual variance without compromising productivity

• Information4.

DELIVERING

1. FORECASTI

NG

2. MATCHIN

G

3. ESTABLISHI

NG

PatientMonitoring Responding

SSHWP Model

IOC Roadmap

Agreement on a

Shared Vision

Confirm membership of CCPG (Plus the project plan)

Communication Plan - Social

Movement / Culture Change

·AirNZ Visits, CCDM Think Tank, Vision Forum – COO, DON, Medical and Nurse Leaders, IT, DSAs, Non Clinical Support, SIU, Allied Health, Radiology

·Agreement to jointly proceed with IOC and CCDM project plan and confirm membership for governance overview for the process of change

·Resource commitment including training and education for CCDM members and others.

•Set up Steering group , agree TOR

•Communication on initiative to staff

•A culture change/ social movement targeted. Confirm change management and communication strategy

The 6 IOC Work Streams

Co-location of

Operations Staff

Forecasting and

Planning / CCDM

“Status at a

Glance” Data

Views

Daily IOC Meeting SOPs

Working Relationships

Face to face problem solving

Innovation over the cooler

Staffing units :RMO unit RN Bureau Admin BureauOrderlies and security

CoordinatorHospital Coordinator Duty ManagersEmergency Planners

From data bases - TrendCare, Webpas

Proving to be very accurate

Allows for Evidence based planning and staffing

Built within the organisation, cost effective

Organisation wide visibility and understanding/ awareness

IT harnessed the data to increase understand around what is happening

Scheduled work visible to all

Enables early identification of exceptional circumstances

Enables informed conversations across key groups for problem solving

Operational oversight

11.30am Daily Operations Team Meetings - MDT, Whole of Hospital focus Operational decisions not made in isolation

Yesterday, Today, Tomorrow Improvement Model

VRM / CCDM

Each team develops a VRM.

Provide framework and context for escalation care capacity decision-making

A live document

ED SOP Developed (Northland DHB)

Acute Patient Journey SOP developed

Reflects patients location and stage of journey

Whole of hospital agreement

A live document

Forecasting

5 years of data

Proving to be accurate

Source, local data bases, Trendcare

Allows for base line planning

Staffing to need (evidence based)

Built within the organisation, cost effective

Standard Operating Procedures -SOPs Agreed Response Plan in advance with Front Line Staff and

Service Leaders Standard Operating Procedures (SOP) – Agreed Business as

Usual patient flow processes Variance Response Management Plans (VRM) – Essential Care

Protocol

On the Day SOPs used predominantly to unblock process constraints SOPs are developed and proposed in response to lessons

learnt and evidence from the yesterday, today, tomorrow cycle VRMs are used when capacity and demand move into a

mismatch

Its about what's best for the patient and how the organisation can organise capacity to best deliver this

CCDM - Matching Resource

Mix and Match – HIA, medical floors, ED, APU

Staffing to forecasting

Capacity management - 3A closed, CSU open

Medical resource in APU

SOP

Julie Chapman Learnings/ ActionsFri Sat Sun Mon Tue Wed Thu Fri Yesterday Fri Sat Sun Mon Tue Wed Thur Fri

6 Hr: 74% 91% 77% 87% 90% 94% 93% 100% 100% 100% 100% 100% 98% 100%ED presents fcast 118 109 131 122 120 110 105 118ED Presentations: 121 107 111 124 118 116 104Acute/arr ad fcast 54 32 30 56 51 59 54 54Acute/arr Admits: 47 25 29 52 47 47 40% Admitted via ED 39% 23% 26% 42% 40% 39% 35%Elective Admits 8/3 0 2/1 12/1 10/2 7/5 13/4 2/2Discharges fcast 64 24 20 55 56 61 56 64Discharges Actual 67 32 15 51 77 63 64Discharges Pred TC 23 9 10 14 19 22 26 26

Today Est. Dchges

Occ at 1100 low 14ED

Staffing Variance

RMO

Acute OT

CT/US

General X ray/Fluoro

A. Health

Clerical Support

Hosp.Supp.Svcs.

Exp. Discharges Tomorrow:

ED

Staffing Variance:RMO

Acute OT

RadiologyA. Health

Hosp.Supp.Svcs.

2692% fine

Safety Watches

Tomorrow

3 in w/r.

695 mins on board. 2nd acute OT on

12 pts waiting for CT, some OP CTs deferred

level of confidence in power board 50%. Non essential on temp board until essential circuits moved over. Reduced

lighting/power rad/basement. No impact CT. Next Sat 24th 0700 north

power local transformer cut to trans to board. Outage of about 5 mins x 2 to

liven temp board B. level of confidence then 80% Longer outage for migration

to be planned meeting next week. St Patricks day Sat.

Whakatane

Daily Operations Meeting Date: 16/3/2012 1130.

Good ED performance, numbers to prediction

Surg CME day, therefore possible capacity to close beds later today or over weekend ? 1d to close if

possible

95%

Yesterday

redeployment/ SW covering within. Sick calls x 3 so far fro pm, nasty cold doing the rounds

Weather

Flow and LOS Initiatives and Impacts

EDD on Trendcare and WardViewCNS stream in EDAppropriate use of OBSIncreased APU capacity with chairs,

APU RegAllied Health Weekend TrialPhlebotomy Rounds earlierTransit lounge surge capacityAcute response by IP teamsRed Triangles Ward ViewStructured Daily Meetings on Ward

Nek Minute - VRM

Variance Response

Management

What does Care Capacity Variance look like?

There is the capacity available to offer more health care to more people

The capacity is about right to efficiently provide quality care which demands reasonable work effort

Safe effective care can be provided with extra work effort and some change to how care is organised

The ability to provide safe care is at risk. Care is being rationed. Resources are being diverted away from direct care and into service rearrangement

Care and safety are being compromised. The system is gridlocked. Resource attention is being directed at the system rather than the care

Variance Response Management Matrix

Mauve Green Yellow Orange Red

Exec. Management

Service Leadership/Ops Management

Ward Unit

1. The Variance status (Colours) are defined; Mauve Extra capacity Green Capacity matches demand Yellow Early variance Orange Significant care capacity deficit Red Critical care capacity deficit.

Ward/Unit Variance Response Action PlanMauve Green Yellow Orange Red

NursingCNM/Delegate determines plan for the shift and communicates with Duty Manager

Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.Review patient management plans.

Offer staff for period available (e.g. 1 hour, 2 hour, 4 hour, meal relief, full shift).

Staff maybe directed to area of greater variance in cluster.

Review staffing for next 24hrs.

Pull patients in from other areas (e.g. outliers or ED)

If staff not required, consider offering annual leave or time in lieu (if owing).

Consider quality improvement activities

Ensure appropriate timely referrals to Allied Health

CNM/Delegate determines plan for the shift and communicates with Duty Manager

Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.Review patient management plans.

Escalate to medical team any patients not seen in last 24hrs.

Staff maybe directed to area of greater variance in consultation with Duty Manager.

Review staffing for next 24hrs.

Consider capacity to ‘pull’ patients in from other areas (e.g. outliers or ED)Consider quality improvement activitiesEnsure appropriate timely referrals to Allied Health

CNM/Delegate determines plan for the shift and communicates with Duty Manager.

CNM remains on the unit.

Consider reallocating staff to balance skill mix across floor

Expedite discharges:Review EDD for patients’ expected to discharge in next 24hrs.

Review patient management plans.

Escalate to medical team any patients not seen in last 24hrs

Repatriation of patients to other facilities.Identify patients who could be put in to the lounge to await discharge.

Review staffing for next 24hrs.Reassess status in 1 hour

As per Yellow plus:Notifies Duty Manager and requests specific resource eg additional staff or admit stop.CNM take on floor co-ordination role.Consider overtime, extended shifts and/or calling in part time staff.CNM considers utilisation of all staff present e.g. orientation staff and students.Ensure ward/unit MDT are aware of status.Consider notifying Nurse Leader.Put agreed care rationing measures in place including rounding.Compile activity sheets for staff coming to assist for short periods.Ensure patients and on-ward relatives aware of status.Reassess status in 1 hourComplete Reportable Event form (REF) inclusive of Trendcare variance.

As per Orange plus:Mandatory reporting to Duty Manager and, Nurse Leader.

CNM to arrange for staff to stop all non clinical activities, e.g. cancel staff training.

CNM take on floor co-ordination role.

Implement “admit stop’Put ‘life and limb’, agreed care rationing measures in place including rounding.

Reassess status in 30 minutes

And so how does the IOC relate to the MOH 6 Hr Target….

The IOC provides for a targeted focus on patient flow:

Patient flow -variation and constraints on the day

When the planets align - 95%!!

When they do not – we identify which planet

Initiatives are live evidenced

Impact of change is monitored live

Variance in the Daily 6 Hr Target Performance

What enabled the IOC implementation?Having a whole of hospital shared vision

Leadership by senior management and clinical leaders

Hearing concerns to the fullest and champions addressing them

Working hard on awareness across the organisation – social marketing

Proactive implementation – whole of hospital

Positive OutcomesOrganisational ability to learn, and translate into

actionIOC operational staff report enhanced problem

solving - face to faceConversations are informed by Status at a Glance

screens - scene setting Silos reduced for operational decision makingWorking in the “tomorrow” and less surprises

todaySOPS - shared understanding Variance Response - unified language using the

‘colour’ systemTransparency between departments - visual

picture of the organisation statusTimely Data EntryDeveloping trust – bridging gaps

The FutureHospital Dashboard, Hospital Schedule,

Electronic Whiteboards

What else would staff find useful?

GO TEAM nominated Awards, Making Change that Matters Competition

Mechanism to identify Patients at Risk

Trendcare Patient Pathways

Awaiting VRM audit results