Policy as imagined and practiced in the Emergency Department

Transcription

1 Policy as imagined and practiced in the Centre for Applied Emergency Department King s: Jonathan Back, Janet Anderson. Glasgow: Alastair Ross Jonathan Back Centre for Applied

2 My background in Human Factors Forcing functions that mitigate error Cognitive models of routine procedural tasks when using devices (such as IV pumps) and artefacts (such as medication charts). Organisational processes that allow teams to adapt to pressures safely Situated understanding of the signals that people use to identify that risks are increasing. Enhancing the organisation s ability to avoid crunch points.

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6 Escalation Policies RCEM recommends that all EDs should have an escalation policy and should be based on an understanding of patient flow pressures (triggers). We reviewed 12 NHS Trust policies and found 92 actions. Action aims: increasing capacity, reducing demand and increasing efficiency. Involved: relocating patients, adjusting processes or resource use, additional staffing or flexing. These were all action-oriented rules. Saving time and effort in reinventing the wheel. Predictability in response.

7 Escalation Policies Each trust develops their own policy but they are similar. Policies are frequently updated. Many recognise the need for a hospital wide-response but the focus remains on the ED. Management records when escalation is needed. are escalation policies useful?

8 St Thomas Emergency Department attendances per day A hospital-wide escalation policy with 30 actions 200 ED Protocols available on the S Drive!

9 When are policies triggered? Centre for Applied Demand indicators such as emergency department occupancy and waiting times are traditionally used for monitoring flow. However, it is difficult to isolate a single point in downward trajectory. Early-warning signals that the system is approaching a critical threshold / tipping-point can be subtle and are not always captured by the numbers.

10 Pressure signals that we Identified Failures in routine task coordination: Not being able to share the prerequisites that need to be achieved before key actions can take place exacerbating the likelihood of downstream lags. Failing to manage disruptions: When senior staff become sucked-in this is disruptive to normal processes. Not being able to assign routine tasks to other members of staff. Misalignments between demand and capacity: Skill mix issues, staff shortages and equipment availability result in adaptations to care delivery.

11 Specialist situational awareness roles At the sharp-end (on the shop floor). Allowing others to get on with clinical work. ED situational awareness roles: Physician-in-Charge, Nurse-in-Charge, Streaming Nurse and last but certainly not least Patient Flow Coordinator (FlowCo).

12 Early-warning signals "The tap" on a physicians shoulder. Murky admission pathways into the hospital. Chasing-up things that have been forgotten or are lagging. Laps and board rounds rather than occupancy and waiting times.

13 Escalation in practice Requires knowledge of the right person to talk to, tact, skill and perseverance (and sometimes the ability to take abuse from consultants on the wards). Although the FlowCo role has become critical to the functioning of an Emergency Department, it is a challenging role with very little formal training or tool support available. At the organisational level assumptions are made about how processes normally work. For adaptations to be effective, the gap between work as done and work as imagined needs to be renegotiated on the shop floor.

14 Work as imagined

15 Q1. Do we know what resilient performance look like? Success Service Manager Work as Done Adaptations Adjustments Failure Eg harm, breaches of targets, standards, staff burnout, complaints, poor experience

16 Q2. What goes in this box? Success Work as Done Adaptations Adjustments Failure E.g. harm, breaches of targets, standards, staff burnout, complaints, poor experience

17 Learning? Performance metrics are disseminated each day for the previous day. Review of breaches focuses on classification and justification not actions and their effects. RCA performed if performance was very bad. Learning from success - successful avoidance of breaches is not discussed. Effect of escalation actions not known!

18 Our Monitoring Intervention Two hourly SITREP meeting with representatives from all ED areas. Reports on patient numbers in each area. Reconciles with IT system lag. Identifies pressures. Effect of adjustments and adaptations previously not monitored. No history every day is a new day! Ownership issues.

19 Method Observation of 2 hourly meetings in Emergency Department (bespoke) SITREP Data Emergency Department current status

20 Re designed SITREP Ownership Monitoring Actions Implemented

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22 Evaluation After training, the SITREP sheet is now being used as a tool at 2 hourly meetings rather than just an audit sheet. The meeting encourages reflection on action which is critical as it supports adjustments and adaptations. It both increases awareness of pressures across the system and facilitates decision making.

23 Work as Imagined Centre for Applied Outcomes Differing definitions of success Clinical outcomes physicians. Patient flow nurses. Uneasy co-existence of sometimes conflicting goals. All breaches are seen as equal - context of the demands not taken into account. Demand e.g. patient numbers, targets Alignment Capacity e.g. staff level, staff skills Work as Done Adaptations Adjustments Success Failure e.g. harm, breaches of targets

24 Work as Imagined Centre for Applied Escalation Adjustments Invoking escalation creates extra demands. Planning and prioritising. Staff handover. Demand Align Work as Done Success Skills assessment and matching. Capacity Failure Escalation is avoided if possible to deal with problems. Degraded response. Crying wolf.

25 Escalation Problems Unclear which metrics are most important. Timing of escalation is important. Previously successful actions no longer work. System becomes uncontrollable and opaque.

26 Resilience perspective Adaptive capacity concentrated in one or two dedicated roles. Need to unpack the black box of patient flow. Unclear which metrics are most important. Limited monitoring of actions taken to manage flow. Inadequate review of effective responses. Implementation of escalation is subject to adjustments and adaptations that are poorly understood but which are crucial to success and failure.

27 Implications Opportunities for improvement. Making the escalation process more transparent understanding repertoire of adjustments and adaptations and under what circumstances they are successful. Improved monitoring of escalation actions better targeting of actions taken during Sitrep meeting. Improved learning from what goes right reports of previous day to include reflection on what worked and what didn t.

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29 Jonathan Back Centre for Applied (CARe)