Redesigning care delivery in British Columbia

Redesigning care delivery in British Columbia

ORIGINAL ARTICLE Redesigning care delivery in British Columbia Lynn Stevenson, PhD; Karen Parent, BScN, MSc, MPA, PhD(c); Mary Ellen Purkis, RN, BN, ...

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Redesigning care delivery in British Columbia Lynn Stevenson, PhD; Karen Parent, BScN, MSc, MPA, PhD(c); Mary Ellen Purkis, RN, BN, MSc, PhD

Abstract—Phase 1 of this initiative was designed to examine the current state of practice in acute care and to provide administrators with research evidence for identifying areas for improvement. Data were collected through observational research using function analysis augmented by a staff survey and interviews. Data were collected from 17 acute care sites across Vancouver Island and the Mainland of British Columbia involving four health authorities.


his article provides a summary of the first 2 years of Vancouver Island Health Authority’s (VIHA) implementation of a major long-term strategic initiative referred to as Care Delivery Model Redesign (CDMR). CDMR was developed in response to VIHA’s recognition that the combination of growing staff shortages and an outdated care delivery model no longer met the needs of an aging patient population, presenting a challenge to the sustainability of VIHA’s service system. VIHA believes that a new model of care delivery is needed to support its staff to optimize their scope of practice, improve the use of existing resources, and improve patient care so the goal of the “right people in the right positions, doing the right work” can be achieved.1 Although many factors contribute to these challenges, an aging population and the shift in the nature of their care needs were key drivers. It was believed that all VIHA care staff should have the skills and knowledge to provide quality geriatric care. Programs and policies need to be sensitive to the populations’ unique care needs such as focusing on maintaining independence and mobility and taking greater care to ensure that older patients experience well-planned and supported discharge from hospital to the community. The design of facilities also needs to recognize the aging population by aligning with recognized principles of elder-friendly organizations.2,3

CARE DELIVERY MODEL REDESIGN Aims and objectives of CDMR In an effort to respond to the changing care needs of the aging patient population and enhance the capacity of their

From the People, Vancouver Island Health Authority, Victoria, British Columbia, Canada (Dr Stevenson); Workflow Integrity Network (WIN) Ltd., Duncan, British Columbia, Canada (Dr Parent); and University of Victoria, Victoria, British Columbia, Canada (Dr Purkis). Corresponding author: Karen Parent, BScN, MSc, MPA, PhD(c), Workflow Integrity Network, 1808 Stamps Rd, Duncan, British Columbia V9L 5W2, Canada (e-mail: [email protected]). Healthcare Management Forum 2012 25:16 –19 0840-4704/$ - see front matter © 2012 Published by Elsevier Inc. on behalf of Canadian College of Health Leaders. doi:10.1016/j.hcmf.2011.09.009

healthcare resources, the VIHA and three other British Columbia Health Authorities (ie, Fraser Health, Interior Health, and Northern Health) participated in CDMR to generate an evidence-based understanding of how staff practice in their current acute care setting. With this understanding, the British Columbia Health Authorities could move evidence to action and revise the models of care delivery and positively influence staff and patient outcomes. CDMR places high value on the “centrality of caring to enhance the patient and staff experience.”4 Specifically, the objectives of CDMR are to (1) optimize the scope, role, and functions of the care team members; (2) improve care quality and safety; (3) increase patient and staff satisfaction; and (4) decrease non-value added work.

The process From the context of an aging population and associated practice issues, the VIHA senior leadership worked with the Workflow Integrity Network (WIN) Ltd., the external vendor selected to support the CDMR initiative, to adapt their proprietary Function Analysis (FA) tool5 to gather quantitative data on provider team members in selected programs, units, and facilities. Workload and activity measurement was first used in the 1970s to increase efficiency and productivity in hospital units to address staff shortages. More recently, a number of other researchers have applied it to gain a better understanding of the functional contributions of all members of a healthcare team and, in doing so, support the redesign of how care is delivered.6-10 VIHA’s purpose in using the FA as the basis for the CDMR data collection was precisely this, to understand the functional contributions of all members of the healthcare team to support the care model redesign. Phase 1 of the work was aimed at understanding the “current state.” Phase 2 engaged the staff in change commensurate with the issues arising out of the finding from phase 1, and phase 3 is focused on evaluation and monitoring activities. For phase 1, the FA methodology was applied to 10 sites geographically dispersed throughout Vancouver Island and the mainland. Within those sites, 17 medical and surgical units located in community and tertiary care hospitals were


engaged. The composition of staff for the work-sampling studies was chosen to ensure that all core disciplines providing care on the unit were invited to participate. Therefore, all staff roles and functions observed included nursing, allied health, non-regulated providers (registered care aide, personnal support worker, and so on), administrative support, clinical nurse leaders, educators, and the community liaison from home and community care. Phase 1 took place between March 2007 and May 2008. Given the strategic and innovative nature of this work, the research was vetted through ethics review and approved. The FA involved the systematic continuous collection of directly observed multidimensional work data using a palmheld device (personal digital assistant). During the observation period, usually 24 hours a day, 7 days a week, over a 1to 2-week period, measurable tasks and activities were observed for each provider as well as with whom staff communicate (ie, peers, physicians, family, patients, and so on) and how (ie, face-to-face, fax, phone, and so on) and the main topics of conversation. Fields for observations are based on a predetermined classification of defined tasks and activities and approved by staff. The data are then analysed to determine patterns and trends over time. The aggregated findings are used to identify areas needing improvement, to assist in setting priorities for change, and to provide a baseline for evaluating the success of selected improvement strategies. The data collection took place over two timeframes gathering data over 3,000 shifts representing 30,000 staff hours worked. Over 1.5 million observations were recorded on nearly 1,000 staff caring for over 700 patients to provide a comprehensive and detailed snapshot of the work being done. Augmenting the FA data were qualitative data gathered daily from staff asking them to describe how busy they felt on their shift, whether their day was a typical day or not, any ideas for improvement, and if they met the care needs of their patients that day. This information was essential for situating the FA data into context. Staff were also asked to fill out a survey that asked questions about their work life, job satisfaction, violence in the workplace, perceptions of the quality of care, and demographic data. Finally, select administrative data including census data; staffing data; and admission, discharge, and transfer data were also obtained to assist with describing the patient population because the FA tool was not designed for that purpose. The findings are reported back first to management and then to staff within 2 months of the data being collected to maintain momentum. Once results and recommendations were reviewed, an action plan was developed for transitioning the recommendations into the workplace.

their full scope of practice; a significant proportion of the workload of many professionals is devoted to activities that could be done by assistive personnel. This means professional staff do not have the opportunity to perform the work for which they are academically prepared. Staff participating in debriefs after the CDMR assessment process frequently conveyed personal frustration with the lack of opportunity to use their skills to assist patients to achieve their goals. This frustration likely contributes to dissatisfaction and may lead to resignations and premature retirements, exacerbating current staff shortages.11 Also, this downward shift in the scope of work means that the organization’s highly qualified resources are not being well utilized.


*The hummingbird effect is a term given for a quick burst of patient contact by healthcare providers not unlike hummingbirds who have been described as angels (ie, now you see them now you don’t). The term was coined in 2009 by Karen Parent, CEO Workflow Integrity Network, from analysing and interpreting observational data using her FA tool over the past decade in healthcare.

Scope of practice The CDMR assessment process showed that many VIHA staff members do not have the opportunity to optimize

Non–value added activity As well as not having the opportunity to work to their full scope of practice, the CDMR analysis also revealed that a significant proportion of staff activity is devoted to a variety of tasks that are likely to provide relatively little value to patient care. All roles included in the research were observed spending a large proportion of their time looking for equipment, providing directions to visitors, completing forms, traveling within the assigned care unit, and so on. For example, in the absence of a functional, mechanical lift, a nurse will have to ask another staff member to leave his/her duties to provide assistance in safely moving a patient. Another example are forms being used despite the fact that the information is no longer required. Previous research has noted that there are many factors that influence the amount of time staff can spend with their patients.12 Staff time is finite; time devoted to non–value added activities results in less time being available for value-added care for patients. The CDMR observational process revealed that the time needed for important activities requiring professional skills and expertise, such as patient assessment, mobilization, and discharge planning, is being consumed by these other tasks. For example, only 20% of registered nurse time was recorded as “direct patient contact,” and within that, many staff-patient interactions were what one of the primary researchers has described as the “hummingbird effect” (ie, quick patient contact with little opportunity for meaningful exchange in terms of advancing the resolution of health issues*). Despite 2 decades of literature supporting the importance of early discharge planning; the FA data revealed that nurses on average, spend only 5% to 7% on this critical function.13

Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012


Stevenson, Parent, and Purkis

Keeping in mind the needs of the growing elderly population, having focused time to care for patients is critical, from functional assessment to reassurance. For example, without early mobilization, hospitalized elderly patients can experience a decline in their level of functional independence, preventing them from returning to independent living and potentially becoming another alternative level of care statistic waiting for a residential care bed.14

PUTTING IT TOGETHER Overall, the CDMR current state findings were similar across the participating sites, suggesting that they may represent system-level issues that are not limited to a single community, facility, or program. To the extent that professional care is systematically focused on priorities other than patient need is a clear signal that system-wide approaches to change care delivery models are essential to identify, implement, evaluate, and share across practice settings and jurisdictions. Many staff members confirmed that the findings reflected their experience and expressed frustration with being so busy yet having so little time to provide direction on the care plan. They recognize the plethora of work that seemingly has little direct value for patients or their families (ie, finding, fixing, forms, and traveling) and the extent to which these activities interfere with spending their valuable time with patients and being able to use the full scope of their knowledge and skills. Many expressed their sense of powerlessness to influence change within the “system” and indicated they felt they had few opportunities to make the changes they knew were needed.

CONCLUDING REMARKS The FA methodology provides a unique means to gather a comprehensive dataset that can be used to inform leaders and frontline staff of the “current state” of care delivery on the inpatient medical and surgical hospital unit. The quantification of activities of the care team captures a thorough representation of how staff time is spent on the unit within their current context. As a result, the highly granular data allow opportunities to improve the quality of care and gain efficiencies in practice to emerge and create leverage to drive the redesign of care delivery and staffing models in acute care. Moreover, the ability to measure and quantify the complex work of the care team is further strengthened by capturing their observable tasks and activities performed; this enables decision makers to identify factors contributing to staff members’ ability to work within their full scope, role, and function. Phase 2 of the VIHA CDMR initiative will use the findings from the FA data to inform changes to current practice and care-delivery models. In addition to guiding practice changes, the data have informed the development of a new staffing model to meet the care needs of their population. Changes ensuring staff work to their full scope, role, and function and realigning activities of the care provider with the care needs of the patients will be fully incorporated in phase 2, whereas phase 3 will involve a formative and summative evaluation. Overall, CDMR and the use of the FA methodology has provided a rich source of unique information to inform many aspects of the transformational changes required in the British Columbia healthcare system and will hopefully contribute to future sustainability.

REFERENCES EVIDENCE TO ACTION: OPPORTUNITIES FOR CHANGE As a result of conducting an extensive and comprehensive analysis, the VIHA was challenged with determining how to proceed from the evidence generated into action to the primary activity for phase 2 of the initiative. Even though the action plan had not been fully articulated by the end of phase 1, staff had begun to implement unit-based activities aimed at improving care based on the research findings. Although successes at the unit-based level are necessary and are occurring, it is at the systems/regional level where change can fully maximize the impact along the four critical pathways of optimization, quality and safety, satisfaction, and a decrease in non–value added activities. Moreover, ongoing recalibration, improvement, and evaluation activities will be influential and vital for sustaining change. 18

1. Vancouver Island Health Authority (VIHA). People Plan: Infrastructure Plan Update. Unpublished Internal Document 2009/ 2010. August 2009. 2. Duxbury L. Work-life Conflict in Canada in the New Millennium - a Status Report [online]. Sydney Papers. 2003;15:78 –97. 3. Parke B. Physical design dimension of an elder friendly hospital: an evidence-based practice review undertaken for the Vancouver Island Health Authority; 2007. Victoria, British Columbia, Canada, University of Victoria, Centre on Aging. 4. Henderson A, Van Eps MA, Pearson K, et al. “Caring For” Behaviours that indicate to patients that nurses “care” about them. J Adv Nurs. 2007;60:146 –153. 5. Parent KL. Function Analysis Tool (version 4) [Workflow/ Work-sampling software]. Duncan, British Columbia, Canada; 2004. 6. Capuano T, Bokovoy J, Halkins D, et al. Workflow analysis: eliminating non-value-added work. J Nurs Adm. May 2004;34: 246 –256. 7. Eastaugh SR. Hospital nurse productivity. J Health Care Finance. 2002;29:14 –22.

Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012


8. Eastaugh SR. Hospital nurse productivity enhancement. J Health Care Finance. 2007;33:39 – 47. 9. Walker K, Donoghue J, Mitten-Lewis S. Measuring the impact of a team model of nursing practice using work sampling. Aust Health Rev. 2007;31:98 –107. 10. Upenieks VV, Kotlerman J, Akhavan J, et al. Assessing nursing staffing ratios: variability in workload intensity. Policy Polit Nurs Pract. 2007;8:7–19. 11. Begat I, Eefsen E, Severinsson. Nurses’ satisfaction with their work environment and the outcomes of clinical nursing su-

pervision on nurses’ experiences and well-being. J Nurs Manag. 2005;3:221–230. 12. Upenieks VV, Akhavan J, Kotlerman J, et al. A paradigm shift in patient care delivery. Nurs Econ. 2008;26:294 –300. 13. Naylor M, Brooten D, Jones Rl, et al. Comprehensive discharge planning for the hospitalized elderly. A randomized control trial. Ann Intern Med. 1994:120999 –121006. 14. Canadian Institute for Health Information. ALC in Canada. Canadian Population Health Initiative. Ottawa, Canada: CIHI; 2009.




Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012