Hagstrom, J. Nathan, MD, MHCM

Hahn, Toni A

Herr, Courtney

Steidinger, Josephine

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksResearch Scholars Poster PresentationChildren’s Cancer Center as a ClinicalMicrosystem: AssessmentJosephine SteidingerJosephine.Steidinger@lvhn.orgCourtney HerrCourtney.Herr@lvhn.orgToni A. HahnToni.Hahn@lvhn.orgJ. Nathan Hagstrom MD, MHCMLehigh Valley Health Network, j_nathan.hagstrom@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/research-scholars-postersThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtSteidinger, J. Herr, C. Hahn, T.A. Hagstrom, J. N. (2019, August). Children’s Cancer Center as a Clinical Microsystem: Assessment. PosterPresented at: LVHN Research Scholar Program Poster Session, Lehigh Valley Health Network, Allentown, PA.Lehigh Valley Health Network, Allentown, PennsylvaniaClinical Microsystems• Defined as small, organized groups of clinicians and staff working together with a shared purpose to provide the best possible care to a defined set of patients• Provide a frame for performance improvement efforts at the local level, which are essential for organizational success. • The Dartmouth Institute has created a clinical microsystem model for improvement, which includes an assessment of the 5Ps (Purpose, Patients, People, Processes and Patterns) leading to formulation of themes, global aims and specific aims followed by idea generation and testing using sequential PDSAs (figure 1).Characteristics of High Reliability Organizations • A study conducted by Dartmouth in the 1990s identified key characteristics of high-performing clinical microsystems (figure 2).  Karl Weike and Kathleen Sutcliffe identified characteristics of high-reliability organizations, which have been applied to health care.  Specifically, our children's hospital has successfully deployed these principles to improve quality of care and patient safetyThe Importance of Colleague Engagement to High-Reliability• Training, continuing education resources and colleague support are directly related to colleague engagement.2 Performance and confidence in ability increase with personally and professionally satisfied employees3 Purpose: We chose the Children’s Cancer and Infusion Center at the Lehigh Valley Reilly Children’s Hospital as a model cell for using the clinical microsystem approach, high-reliability principles and employee engagement theory to guide an assessment of the children's cancer and infusion center and explore opportunities for improvement.  Staff Interviews• Selective communication of ideas• Not adequately trained on insurance, limited new hire training, limited continuing education resources• Physicians seeing patients in timely fashion is inefficient and variable• No emotional support/lack of trauma stewardshipClinical Microsystem Assessment Tool• Lowest scoring categories (3.33 out of 5) were regarding process improvement and training and resources• Highest scoring category, and the only category with a score above 4 out of 5, was regarding patient focus in the CCCDaily Post-Huddle Surveys• Statements about effectiveness, efficiency, how pertinent discussed information was and how on task discussions were all scored below 4.75 out of 5Colleague Engagement Survey“People look for the confirmation that they’re correct, not that they’re wrong”1Colleague Engagement for High Reliability • Lack of training and information access, specifically among nurses, created an unsupportive environment when new staff began working at the CCC• Trauma stewardship was identified as an issue in both staff surveys and staff interviews• CPHON certification among nurses was identified as an opportunity for improvement• Minor deviations in patient safety protocols create waste and extra work in the CCC, yet may not add to high reliability• Management system practices could be improved to better engage colleagues in improvement effortsPatient Flow• Assessment of the patient flow journey validated results of a previous study done in the CCC that showed patients waiting >30 minutes to see physician• Lack of consistent processes, such as whether or not a patient got roomed, when physicians saw patients and when labs were ordered, created lag time during the patient flow journeyCommunication and Information Sharing• Variability, inefficiency and usefulness of daily huddles was identified as an issue• Staff concluded that safety and high reliability could be improved with better communication and information sharing• Psychological safety could be improved by strengthening the perception that speaking up is welcome and that the opinions of others are valuedREFERENCES1. Weick, K. E. (2007). Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco, CA: Jossey-Bass.2. Sarti, D. ( 2014). Job resources as antecedents of engagement at work: Evidence from a long‐term care setting. Human Resource Development Quarterly, 25( 2), 213– 237.3. Xanthopoulou, D., Baker, A. B., Heuven, E., Demerouti, E., & Schaufeli, W. B. ( 2008). Working in the sky: A diary study on work engagement among flight attendants. Journal of Occupational Health Psychology, 13( 4), 345– 356.4. Adapted from The Dartmouth Microsystem Improvement Curriculum (12 pg 9)5. Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002). Microsystems in Health Care: Part 1. Learning from High-Performing Front-Line Clinical Units. The Joint Commission Journal on Quality Improvement,28(9), 472-493. doi:10.1016/s1070-3241(02)28051-7Colleagues• Staff Interviews• Clinical Microsystem Assessment Tool• Daily Post-Huddle Surveys • Colleague Engagement SurveyPatients • Patient Survey• Patient Flow Tracker/Time StudyProcesses and Patterns• IHI HRO Journey Assessment Tool• AAP Standards for Pediatric Cancer Centers• Toronto Sick Kids Proposed Pediatric Cancer MetricsHigh Reliability• The CCC will become a model of high-reliability systems, tools, practices and behaviors for other areas to follow, both at Lehigh Valley Reilly Children’s Hospital (LVRCH) and other children’s hospitals Patient Flow• Improve the patient flow process to reduce wait times and improve both the patient and family experience as well as the colleague experienceColleague Engagement• Create consistent and reliable processes for common functions with more effective education and training for staff, and improved communication and information sharing• Improve psychological safety• Improve trauma stewardship and reduce risk of burnoutDaily Huddle• Improve the efficiency and effectiveness of morning huddle• Promote colleague engagement in ensuring patient safety and continuous quality improvementIntervention techniques addressing daily huddle, patient flow and colleague engagement are recommended Background & PurposeMethodsResults DiscussionConclusionsChildren’s Cancer Center as a Clinical Microsystem: AssessmentJosephine Steidinger, Courtney Herr, Toni Anne Hahn, J. Nathan Hagstrom MD, MHCMHigh Performing UnitsLeadershipCultureSupport from Macro OrganizationPatient FocusStaff FocusCare TeamInterdependenceInfo & Info TechnologyProcess ImprovementPerformance PatternFigure 2: 9 Characteristics of High Performing Units (5)Figure 3: CCC Patient SurveyFigure 1: Dartmouth Microsystem Improvement Timeline (4)Patient Survey• Time spent before seeing clinician & length of time waiting at the office are the only statements <4.5Patient Flow Tracker/Time Study• Patients wait on average over 30 minutes in the Children’s Cancer Center (CCC) to see a physicianFigure 4: Colleague Engagement Survey Statements with Scores <3.5 Among Nursing StaffFigure 5: Colleague Engagement Survey Statements with Scores <4.40  Among All StaffFigure 6 & 7: Patient Check-in Time vs Scheduled Appt Time and Average Patient Wait Time to See Physician by Visit Type

Children’s Cancer Center as a Clinical Microsystem: Assessment

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Children’s Cancer Center as a Clinical Microsystem: Assessment

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