Archives January 2013

Dr. Eleanor M. Jansen trained as a General Practitioner in the UK, and after getting married, moved to the remote island of Kodiak, Alaska where her husband works. She now co-ordinates a palliative care service on the island, and describes her journey, here.

Dr Eleanor Jansen gets to grips with a new system in Kodiak, Alaska.

Living on Kodiak Island, Alaska, the hardest part of my day may actually be making it as far as the hospital entrance: scraping layers of ice from the windscreen, driving the treacherous miles, remembering to park into the wind so my truck door isn’t ripped off, and tip toeing across the parking lot in my ice cleats, looking out for that bear who refuses to hibernate.But once I make it through the door, helping to implement a new palliative care service at Providence Kodiak Island Medical Center has it’s own challenges. The team formed about a year prior to my entering as coordinator and there was already enthusiasm from several hospital disciplines to bring an extra layer of support to patients and families dealing with serious and life-threatening illness.My main challenges are to bring structure to the service, promote the team, educate and plan for the future.

Reading America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals, a 2011 collaboration between the Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC) [1], I feel proud that our little 25 bed hospital has a service at all. Palliative care is one of the fastest-growing trends in US health care and the number of programs within hospital settings has increased by 138 percent since 2000, yet, despite those nationwide improvements, just 2 out of 7 small hospitals in Alaska, with under 50 beds, have a Palliative Care program.

A needs assessment and defining exactly your scope of practice are among the first tasks of setting up a program. Thanks to, among others, CAPC and their wealth of publicly available tools and resources, there is plenty of information available. I encourage programs not to reinvent the wheel, but to seek tools already in use and adapt these to the needs of your team.

Kodiak, Alaska

Beware of selling yourself before your systems, protocols and forms are in place, but do think ahead about advertising your team. There will be pressure to market the service early on, but don’t touch the tar baby! A recent audio conference from CAPC highlighted palliative care services becoming quickly saturated is a common downfall in the start-up phase.Establish relationships with disciplines outside the team – nursing staff, pharmacy, administration – as they will be your advocates and a tremendous support. I also recommend reaching out to various resources and finding out what else is out there to support your service. Here in Kodiak I have made close ties with Home Health (similar to District Nurses), the new volunteer Hospice of Kodiak and I am getting to know about other resources such as the “Senior Center.”

Educating staff about the palliative care team’s role is an ongoing challenge. Recent opinion polling revealed that palliative care is relatively unknown to the US public and poorly understood by many health care providers [2]. Palliative Care’s relationship with hospice is also misunderstood. Here in the US, hospice has more defined parameters based upon prognosis, relinquishing curative treatment, etc. Helping physicians see that early referral to palliative care, in some cases at the time of diagnosis, can help tailor care to patient goals and improve quality of life. Meeting with doctors and other staff on a one-to-one basis and presenting at medical staff and admin meetings has been most effective at promoting the team. Putting together a short ‘elevator speech’ is useful too in those “crunch time” moments. It is worthwhile advertising the service as a time saver to physicians and a team who can have those long and often difficult conversations about treatment decisions, advance care planning, resuscitation and so on.

It has been equally essential to keep the patient’s primary physician central to care and to be seen as additional support versus taking over. In Kodiak, the family physician comes to the hospital to manage the patient. Understandably, physicians here in Kodiak are protective of their patients and the only hand over from family physician-to-hospital staff comes if the patient needs to be flown to a distant facility for treatment unavailable on Kodiak Island. As a GP in the UK, I often breathed a sigh of relief when I handed over a very sick patient to a higher level of care at the hospital, as I knew I was reaching the limits of what I could do in the community. No such relief for physicians here.

Dr Jansen meets the bears of Kodiak Island

What is clear to me, being in a new country, system and environment, is that different places have different habits and things ‘have always been done that way.’ Introducing a new branch of medicine, with it’s growing evidence base, can challenge those traditional ways of doing things, and can take time and effort to be accepted.The son of a patient who died said to me the other week that the involvement of palliative care had brought ‘a sense of calm.’ If that is what we achieve for families, then our efforts bringing palliative care to this island are beginning to come to fruition.

References:

‘Dr Jennifer Perry graduated from Birmingham Medical School in 2008 and moved to London for her foundation years as a junior doctor. She decided to specialise in Psychiatry and in 2010 joined the Royal Free Training Scheme. She is now currently working as a CT3 in Old Age Psychiatry at St Ann’s Hospital’.

Dr. Jennifer Perry describes the challenges to implementing a quality improvement project here.

We undertook a Quality Improvement Project (QIP) to create a workshop for patients with a diagnosis of schizophrenia within the Haringey Community Rehabilitation Team (HCRT). This was a result of the Barnet, Enfield and Haringey Mental Health Trust Patient Experience Questionnaire which highlighted that patients within the HCRT did not feel that information about their medication was explained to them in an understandable way.

Sustainability and Engagement of Staff

We faced a number of challenges to our QIP. One of the key issues was that of sustainability as I, as the project lead, was only part of the team for six months and so there was the worry that the project would be difficult to continue after I had left. There were a number ways we overcame this. The project engaged all HCRT members, as many of them helped to co-facilitate the workshop, and so this ensured that everyone was involved which made it a more sustainable project. A protocol was developed which offered a step by step account of how to plan and implement the workshops which would allow other people to run them. I liaised with the incoming junior doctor to ensure that she would be willing to continue running these workshops, which she was. The project was an agenda item at each team clinical governance meeting which again helped to ensure longevity. Therefore, to overcome the challenge of sustainability, my advice would be to engage all of the key stakeholders early on in the project (including future junior doctors), link the project in with local clinical governance and to formalise the process through writing a protocol.

Engagement of Service Users

A challenge we faced was how to engage service users in the workshops as it was felt that some patients might lack the motivation to attend. We developed a process whereby in advance of the workshop date we would contact the care home and speak with the manager; we would ask the manager to then speak with all of the residents in their care home to tell them about the workshop. We would then send out individual personalised invitations to each service user giving them information about the content of the workshop as well as details of the date, time and venue. Care co-ordinators who looked after clients in each care home where the workshops were being held were asked to speak with their clients to encourage them to attend. Where possible we tried to ensure that the group co-facilitator for each care home workshop was a care co-ordinator who looked after at least some of the service users living there. This highlighted that in order to engage other people in your QIP (this could be patients or staff members) you need to have a variety of methods to promote it and to be proactive in this.

Communication and Organisation

One difficulty we encountered was that there were on occasions miscommunications between our team and the care homes so that two of the workshops had to be cancelled. The lesson learnt from this was the importance of liaising with the care home well in advance of the workshop date and ensuring that this communication was via telephone as well as via email. In order to overcome difficulties such as this it would be advisable to prepare QIP interventions well in advance and maintain good communication with all those involved.

Designing an intervention to meet patient’s needs

Another challenge was that we implemented a workshop which we as mental health professionals had designed. We were uncertain as to whether or not this workshop would meet patients’ needs. To enable us to assess this we built in a section in the workshop introduction where service users introduced themselves and said what they would like to get out of the workshops. The workshops were then made as interactive as possible so that attendees could give their reflections, opinions and thoughts as well as ask their own questions. We distributed feedback questionnaires to the service users at the end of every workshop. As a result of the patients’ feedback and our own observations, modifications were made after each session so that we were able to develop a workshop that was tailored to the needs of the service users. The Plan-Do-Study-Act Cycle gave us a formal structure in which to implement and monitor changes. This highlighted the usefulness of PDSA cycles and the importance of obtaining service user feedback on QIP interventions where it is appropriate (as ultimately it is service users who should be benefiting from QIPs).

(One final piece of advice is that, where possible, your QIP intervention should be something that you enjoy doing, or that you feel passionately about, as this will help you, your colleagues and your patients to get the most out of it!)

In many cases in medical care the systems are inefficient; time is wasted because of a myriad of processes and protocols and a failure to recognise the causes of delay in these processes. Dr. Douglas Woodhouse is a physician-engineer and a healthcare consultant focusing on process improvement. Here he describes a new way to improve wait times.

Dr. Douglas Woodhouse is a physician-engineer and a healthcare consultant focusing on process improvement

Cycle time is the total time that it takes from beginning to end of a treatment process, including treatment of complications. Efficiency rises when cycle times are short because care has been provided in less time, using fewer resources. Because the impact of adverse events is included, it is also an indicator of quality. Cycle time should be adopted as a key indicator of healthcare performance, and in this article I describe how this may be done.

Long wait times for health services are a concern in many health systems. However, it is likely that some efforts to reduce wait times have actually increased the time that it takes to complete treatment. Accepting more new patients into a healthcare process (reducing the wait time) without increasing the capacity of the process merely shifts the patient backlog from before the first to the second appointment.

Because most diseases lead to progressive disability, delays in completing treatment are not just inconvenient, but lead to worse health outcomes and higher costs. In comparison to measuring wait times, or length of stay and readmission rates, cycle time is a superior measure of overall healthcare performance.

1. Cycle time must include complications.

If a hospital just measured cycle time from admission to discharge there would be incentives to skip steps, discharge people home too early, and just deal with problems later on.

The solution is to include the management of complications in the cycle time. Cycle time for surgery would start at the time of referral and end when the patient is discharged home post-surgery. If the patient developed a post-operative complication, the cycle time clock would be re-started.

If cycle time includes treatment of complications, then it is safe and appropriate to reduce cycle time as much as possible. The shortest possible cycle time can only be achieved by providing optimal care.

2. The constraint should be patient intake.

The constraint (or “bottleneck”) is the slowest process step. Wait lists develop before the constraint.

If patient intake is the constraint, then the number of patients starting and completing treatment are matched. Wait times do not grow inside the process and cycle time is minimised.

If the wait list at intake increases, then the capacity of the entire process must be increased (rather than just accepting more patients at intake and hoping for the best).

3. Cycle time must be regularly monitored.

If cycle time increases then wait times inside the process should be measured to find the constraint (not only the wait time before intake, but also wait times before other activities). Wait times should be measured as patient-days. Either a small number of patients with long waits, or a large number with short waits indicates a constraint that should trigger action.

4. Once the constraint has been identified, that activity should be sped up.

Once the constrained process step is sped up, the constraint will shift to a different step. Each constraint within the process should be identified and eliminated (until the constraint moves to intake, where it belongs).

5. Process steps should be allowed to idle.

In a process that is constrained at intake, all other steps have extra capacity. Process steps will have idle time while waiting for a patient to complete the prior step. This is acceptable, and even desirable, as long as cycle time is not increasing.

The shortest possible cycle time is defined by the minimum time required to provide all medically necessary services. Although in general shorter cycle times save money, the minimum cycle time can only be achieved if there are no resource limitations, and therefore relatively high costs. The lower left segment of the curve therefore represents the highest value (short cycle time, low cost and high quality).

6. Process steps should be completed in parallel whenever possible.

Parallel process steps prevent unnecessary waiting for sequential treatment activities and therefore significantly reduce cycle time.

7. Treatment should be as standardised as possible.

At least 80% of patients should progress through the standard process steps. This means that no more than 20% of patients should receive non-standard, individualised treatment. Time that is gained (through greater efficiency) by treating the majority of patients in a standard process can be used for the minority of patients who require extra care.

8. Protocols should be followed for the standard treatment process.

Protocols reduce the variability of the process (and therefore reduce the cycle time). The standard protocol should apply to the 80% of patients that follow the standard process. On the other hand, patients that are not in the standard process should not necessarily be treated according to a protocol.

9. The most expensive process step may justify the creation of a buffer (wait list) to ensure that it is always in use.

The most expensive process step should be maximally utilised. To achieve this, a short buffer (wait list) may be created to compensate for variations in capacity and demand. The maximum wait list for this step should be clearly defined.

If this maximum is exceeded, no additional patients should be accepted into the process until the cause of the delay is identified and fixed.

An Example of Cycle Time in the Operating Theatre

Dr Doug Woodhouse will be participating in a BMJ Quality Webinar on the 15^th January from 5:00 – 6:00 (GMT+0). The session will take place through the WebEx platform at quality.bmj.com.