National Emergency Medicine Programme
Implementation Update November 2012
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These slides provide an overview of:
ED and LIU pathways (slide 2)
ED patient pathway developments recommended in the EMP Report 2012 and First
Steps document. Emphasis is on local adaptation of model to meet patient needs
(slides 3 to 5)
EMP Implementation Approach (slide 6, 10, 11)
Clinical Microsystems (slides 7, 8, 9)
Diagram illustrating Emergency Care as a complex adaptive system (slide 12)
Factors to consider in implementing large scale health system change (slides 13, 14)
Path ahead (slide 15)
Cut and paste, amend and adapt as appropriate to your ED team
1
Patient Pathways – ED and LIUs
ED Arrival
Triage
Seen by treating
clinician
Disposition
Decision
Registration
S/B Admitting
Team
ED Pathway of care
Completion
Admitting team
ED Departure
GP Access to Diagnostics
Rapid Access OPD
Specialty Assessment/Admission Units
LIU Pathway of care
ED Arrival
Registration
Seen by treating
clinician
Emergency Medicine Programme
Disposition
Decision
2
Arrival to seen by treating clinician
Arrival
Registration
Triage
Advanced
Triage
Seen by treating
clinician
Monitoring
Protocol
Ambulance
Handover
Streamin
g
RAT
Mini-registration
Work-redesign
•MTS only
•Standardised triage
•Demand capacity analysis
•Monitor effectiveness
•Pain assessment
•Infection Prevention &
Control
Evidence Based Pathway of care
EMP Report 2012
Chapter 19 & references
•Assess peak demand
•Staffing resource
•Share protocols
• ECG
• Front-load blood tests
• Supply analgesia
• Mental Health Decision Tool
• MTD Assessment
• Frail Elderly
ANP stream
Fast track
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Patient Pathway
Seen by treating
clinician
Review
with results
Monitoring
Protocol
ANP stream
Medical
Workforce
Access to
Diagnostics
Disposition
Decision
Process
Efficiency
Initiatives
Protocol for
patients who leave
before completion
of treatment
Clinical
Guidelines
Condition
Specific
Pathways
Sharing
effective
practice
Emergency Medicine Programme
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Patient Pathway
Direct ward
admission
protocol
CDU
protocols
Process
efficiency
initiatives
Data capture
Diagnostic
coding
Disposition
Decision
ED Departure
S/B Admitting
Team
Completion
Admitting team
Assessment
Transition of
care protocol
Bed
management
Emergency Medicine Programme
5
EMP Implementation Approach
What changes
are needed to
implement
the EMP
in our ED?
EMP
First Steps
How do we
make the change
happen
and sustain
improvement?
Emergency Care
System
Safe, high-quality
reliable, resilient
patient care
and clinical teams
Clinical
Microsystems
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Sustainable Improvement Triangle
Better Outcome
Patient, Population
Better Professional
Development
(health status, patient
experience, illness burden)
(competence, pride, joy)
Everyone
Better System
Performance
(quality, safety, value)
Batalden Davidoff Sustainable Improvement Triangle:
Sustainable efforts in real settings require inextricable linkages
“The combined and unceasing efforts of everyone - health care professionals, patients and their families, researches,
payers, planners, educators – to make the changes that will lead to bettter pateint outcomes, better system
performance and better professional development (learning new knowledge, skills and values).”
Emergency Medicine Programme
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What are Clinical Microsystems?
Patient
Information
Provider
The clinical microsystem is where care is “made”.
It is at this level that quality, safety, reliability, efficiency and innovation
are created along with staff morale and the patient experience.
All other components of the health system exist to
support the clinical microsystem.
www.clinicalmicrosystem.org for further information and resources.
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Activities
Steps
Dartmouth Microsystems Improvement Curriculum
for Emergency Departments
Lead Team
Set up Team
Set up ED COG
Decide way of
working
Set objectives
Assessment
Baseline Analysis
- ED Attendance Data
- ED Profile Analysis
- Purpose definition
- Survey patients,
staff, team skills,
activity;
Process Mapping
Patterns Analysis
Diagnosis
Demand/capacity
planning
Strengths/weakness
analysis
Lean/Six Sigma
approaches
Value stream
mapping
Treatment
Prioritisation matrix
Implementation plan
Plan-Do-Study-Act
Lean 5-S
Other improvement
tools
Follow-up
Lessons Learned
Use ED COG for
Continuous
Improvement Cycle
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Implementation Support Approach
Strengthening
Governance, with
defined roles and
meetings structure
Standard metrics and data
base lining
Knowledge &
Ideas
Detailed, on -thejob coaching to
train entire ED
team and embed
approach within
unit
Outcomes
Continuous
Quality
Stan
Improvement
Context
Training in quality
improvement
including
microsystems,
effective
meetings, process
improvement etc.
Actions
Knowledge, best practise and experience sharing
through website, meetings and seminars
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Putting it all together
Achieving EMP aims for patients, staff and the health system
Ongoing
improvement
Clinical
Microsystems
Improvement Approach
First Steps
EMP Report 2012
ECN Infrastructure,
workforce,
Intelligence, resouces.
ED Clinical Operational
Groups, EMP Implementation
Teams and Programme
Support
Patient participation and
feedback
EMP Outcomes
Measurement
(using baseline data)
National Initiatives
(e.g. datasets, EDIS,
Emergency Care Networks)
Implementation support
from hospital, region, HSE,
SDU, DOH
Building a foundation for sustained improvement
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A Complex Adaptive System
Ambulance
service
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Patients
Volume of demand
Time distribution of
demand
Complexity of casemix
Acuity of casemix
Age profile
Patient perceptions &
preferences
ED
Workforce
• Nursing, medical, others
• Skill-mix
• Agency/locums/overtime etc.
Quality of care
• Evidence based, cost-effective care
• Patient experience
• Process efficiency
• Patient outcomes, safety, risks
• ED infrastructure to match demand
• Access to diagnostics for ED discharges
• CDU care reducing LOS
Primary & Community care
Hospitals for
escalating levels
of care
Linked Emergency
Care Network
Units
System Intelligence
Data capture – EDIS
Outcomes measurement
Process measurement
Cost capture, allocation and management
Acute Hospital
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Supporting on-site specialties and services
Work practices
Access to diagnostics
In-patient bed capacity , utilisation & access
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Improving a Complex Adaptive System
Improvement science learning points:
• Create the conditions for improvement and change
• Try not to increase the chaos in the system e.g. by introducing changes that
are not aligned with overarching goals
• Command and control approaches are less likely to lead to sustainable
change – flexibility, small tests of change and a ground-up approach are
more likely to be effective
Actions:
• Set strategic goals and align improvement to the goals
• Provide essential infrastructure to support improvement
• Track priorities
• Test changes at local level
• Spread and sustain improvement
• Get everyone involved
• Ensure accountability
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Organising Quality Health Care
Six Universal Challenges for Health Systems that Seek to Organise Quality Health Care*
applied to EMP Implementation
Challenge
Description
Structural
Structuring, planning and coordinating implementation actions
Political
Negotiating the politics of change with all stakeholders, getting buy-in,
building change relationships, dealing with opposition, agreeing to a
common adenda for improvement
Cultural
Building shared understanding and commitment
Educational
Sharing and embedding knowledge and continuous learning,
improvement skills and expertise
Emotional
Supporting enthusiasm and sustaining momentum and motivation
Physical and technological
Design and implement a physical, information and technology
infrastructure that improves service quality and patient experience
These challenges exist at ED, hospital, network and national level.
*Bate P et al. Organising for quality: The improvement journeys of hospitals in Europe and the United States. Radcliffe Pub 2008.
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The Path Ahead
National Level:
• HIQA Tallaght Report Implementation
• EMP - sharing effective practice; models of care; supporting implementation
teams
• SDU / DOH/HSE
– Creating the environment for implementation – capacity, focus, priority
– Hospital and regional support
– Workforce issues within emergency care
Local level (customise as appropriate)
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