International Journal for Quality in Health Care 14:463-470 (2002)
© 2002 International Society for Quality in Health Care
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The Victorian emergency department collaboration
1Quality and Care Continuity Branch, Department of Human Services, 555 Collins Street, Melbourne, Victoria, Australia
2The Chinese University of Hong Kong, Accident and Emergency Medicine Unit, Trauma and Emergency Centre, Prince of Wales Hospital, Sha-tin, N.T., Hong Kong
Objectives. The aim of the project was to bring together 17 major emergency departments across Victoria, Australia, and the Australian Capital Territory to work together over an 8-month period to reduce both clinical and operational waits and delays, and to improve patient satisfaction.
Design. The collaborative was based on the Institute for Healthcare Improvement’s Breakthrough Series, and utlilized their intellectual property and methodology adapted for the Australian setting.
Setting. The largest (by annual attendances) 17 emergency departments in the State of Victoria and one hospital in the Australian Capital Territory participated.
Study participants. Each hospital sent a team of three to five persons, which included the Emergency Department Medical Director and Nurse in Charge, and an Executive Sponsor to each learning session.
Interventions. The teams were required to attend four learning sessions, to participate during the action period in both clinical and operational improvement activities, and to report regularly in the form of data reports and conference calls.
Main outcome measures. Each team selected at least one or two clinical topics for improvement and at least one operational project to undertake during the life of the collaborative. A patient satisfaction survey was commenced towards the end of the project.
Results. Forty-seven clinical projects were nominated during the life of the collaborative and 32 of these were completed, with 31 resulting in significant improvement or achieving target. Thirty-nine operational projects were nominated, 30 of which were completed, with 24 of these achieving improvement or target. Numerous additional achievements occurred, which evolved from the framework of supported collaboration.
Conclusion. The spread of knowledge and innovation can be best facilitated rapidly by teams working together using a structured program in a supported environment.
Keywords: breakthrough series, collaboration, emergency department, quality improvement
There has been significant pressure to improve emergency department (ED) performance over recent years, with increasing community expectations and changes in clinical practice, requiring rapid and expert response to emergencies. At the same time there have been increasing delays for emergency patients accessing in-patient beds, causing ED overcrowding or ‘access block’ [1–5]; this has reduced the capacity of EDs to respond to increased expectations. Emergency departments have responded with significant changes in processing of patients, improvements in staffing and departmental design.
The Royal Melbourne Hospital Emergency Department (RMH ED) joined with the Institute for Health Care Improvement (IHI) Breakthrough Collaborative Series in 1999 in an effort to improve performance across operational, clinical cycle times and to improve patient satisfaction. Involvement with this collaborative resulted in considerable improvements in the RMH ED [6]. In particular, RMH ED showed strong improvements in waiting times to analgesia, time to thrombolytic treatment, time to antibiotics in febrile neutropenic patients, reduction in bed request times, and introduced a fast-track system for non-urgent patients. It also began to measure patient satisfaction systematically using international benchmarks.
As a direct result of the RMH involvement, the Victorian Department of Human Services (DHS) funded a state-wide collaborative of major Victorian emergency departments. This was the first time that an IHI collaborative had been undertaken on a geographic regional basis and was being funded by a government agency. The objective of the collaborative was to improve clinical and operational cycle times, and to improve patient satisfaction. This was in the context of an emergency system that was under severe duress due to worsening access block and other key performance indicators, such as waiting times, resulting in poor morale across the system. A secondary objective of the project was to improve collaborations between institutions.
Methods
Design
This was an observational study of the implementation of a state-wide collaborative using methodology from the IHI Breakthrough Collaborative Series [7]. The collaborative was modified for the Australian setting. The collaborative involved four learning sessions, intervening action periods, and regular reporting of results over an 8-month period, from October 2000 to May 2001 (Figure 1). The ‘PDSA’ cycles refer to the Plan–Do–Study–Act approach, a term originally introduced by Shewhard [8,9] and refined as part of the IHI Breakthrough Series. The learning sessions comprised 1–2 days of lectures, interactive sessions, and small group sessions to facilitate hospitals to learn to plan their approach to process change. During the action periods, teams worked on their projects, reported in a set graphical format to the Project Director, and participated in a conference call with the system leader, chair, and project director. Standardization of the reporting format made comparison of teams and provision of support for teams with limited information technology (IT) capability easier.
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Setting
The 17 largest EDs (13 metropolitan, four rural) in Victoria and one ED in the Australian Capital Territory were involved. The EDs varied in census from 20 000 to 60 000 attendances per annum. Each ED had a full-time Medical and Nursing Director and 24-hour medical care by dedicated ED staff. Victoria has the smallest geographic area of the mainland states, with a metropolitan population in Melbourne of 3.5 million and a rural population of 1.2 million.
Study participants
The project was coordinated by a planning group consisting of a Chair, System Leader, Project Director, Epidemiologist, and five clinical experts. The System Leader established the vision, negotiated the funding with DHS, the contract with IHI and facilitated the administrative process throughout the project. This person was the Medical Director at the RMH.
The Chair of the collaborative provided clinician leadership, and along with the System Leader and the Project Director comprised the core group who coordinated the project. The Chair of this collaborative was the Emergency Department Director at RMH, who had participated in the pilot project in 1999.
The planning group was derived from both metropolitan and rural EDs involved in the collaboration, and included doctors and nurses. The planning group was responsible for agreeing on the collaborative goals, identifying the areas for intervention, providing advice and feedback to teams, particularly at the learning sessions, and providing overall multidisciplinary and complimentary expertise. There were no specific operational experts other than the System Leader; however, the ED Directors and Nurse Managers were involved in their own organizations at an operational level.
The Project Director was instrumental in managing the project. She provided day-to-day contact and advice to team members, as well as providing all the administrative support and structure. The Project Director was originally trained in occupational therapy but had recently become involved in quality project work.
Each hospital sent a team, including an Emergency Department Medical Director, a Nurse-in-Charge of the department, and an Executive Sponsor. The Executive Sponsor was usually a Medical Director, Operations Director or Chief Executive who was important in providing a link when changes impacted upon the rest of the hospital. The Executive Sponsor was also the operational expert within the team. The teams varied in size from three to five persons.
Intervention
Each team chose between one to five projects from a suite of six clinical and nine operational improvement projects. Once a topic was chosen, the expected improvements were expressed as specific aims, for example, to reduce the median time to analgesia from time of arrival to 30 minutes. All teams were also expected to be involved in patient satisfaction surveys. A typical list of interventions for clinical and operational improvement is shown in Table 1. The interventions were designed from best available evidence and experience from previous collaboratives. A full list of possible project topics is shown in Table 2. Teams chose projects according to the particular needs of their hospital. Gant charts to detail interventions versus expected time frames were then constructed.
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Funding
The project was funded by a grant of AUS $1.3 million (US $676 000 at the conversion rate of November 2000) from the DHS. Each hospital was given AUS $40 000 (US $20 800) to back fill staff involved in the project and for some administrative support within the hospital (the Canberra Hospital was not funded by the DHS). A full-time Project Director was appointed for the duration of the project. The System Leader and Chair of the collaborative were not funded by the project. A significant proportion of the money was directed to the coordination of the patient satisfaction tool under a contract with Press, Ganey and Associates Inc., a private consulting company specializing in Healthcare Satisfaction Measurement.
Outcome measures
Each team was asked to select projects from those listed in Table 2. Teams were asked to set ‘stretch’ targets for each of these interventions. Success for each intervention was measured against these targets. Teams were assessed against collaborative aims according to the following assessment (Table 3). The Project Director made an assessment together with collaborative teams. A survey of the participants was also undertaken to assess satisfaction with the collaborative and to assess the utility of the methodology.. The survey was designed by the planning group and asked eight general questions about the collaborative, as well as asking respondents to rate level of overall satisfaction with the collaborative on a five-point scale. The survey was completed by the teams as a whole and not by individual members. The survey forms were sent after completion of the final learning session. Although the Director was blinded to the institution, some comments on the survey forms allowed potential identification.
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Results
Participation
All 18 hospitals completed the 10-month period of the collaborative and participated with a full complement of team members in each learning session. This was despite the distraction of severe access block and overcrowding within EDs during this time.
Clinical projects
During the collaborative, 47 clinical projects were nominated by teams, and 33 of these were completed during the 8-month period. Thirty-two projects resulted in a significant improvement or achieved their target (Table 4).
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There appeared to be some projects that most hospitals participated in and which proved most successful. Time to analgesia and thrombolysis were most frequently chosen. Time to analgesia was most interesting in that teams were surprised by their poor performance when they initially measured their time to analgesia from arrival for patients in pain; in one instance this reached 7 hours (median) time. All hospitals recorded significant improvements in analgesia time. A typical example of results is shown in Figure 2.
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Operational projects
During the collaborative, 39 operational projects were nominated, 30 of which were completed and 24 of these achieved significant improvement or reached their target. Despite operational difficulties resulting from access block, many of the projects performed well (Table 5). Some projects were commenced late or were still being planned at the completion of the 8-month collaborative. A graph-report from one hospital on an operational project to reduce time to bed request for patients requiring in-patient beds is shown in Figure 3.
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Overall team achievements
All teams achieved a score of 
3.5, and one-third scored 4.5 according to the rating scale (Figure 4). There was only one minor discrepancy between self-assessment and Project Director assessment. The first report taken after the first action period showed the expected difficulties that most teams had in getting the project moving in the first 2 months.
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Patient satisfaction
Unfortunately, due to administrative problems relating to contractual issues and adaptation to an international collaborative, the Press, Ganey and Associates Inc. satisfaction tool was not implemented across the sites until close to the end of the collaborative. Therefore it was not possible to demonstrate a trend in performance in this area during the course of the collaborative. Initial patient satisfaction results were positive but this will be monitored during the next 24 months with quarterly reports and another learning session, focussing particularly on the details of the outcomes from each site.
Participant feedback
All participants reported positively about the experience, with half describing the project as excellent. Responses were for each team rather than individuals within the team. There was a 100% response rate (Figure 5). Respondents to the evaluation also reported that they believed that the change in processes would continue beyond the collaborative (78%) and that the Breakthrough Series methodology would be used on projects in the future (89%).
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Additional achievements
In the feedback from participants, a number of improvements beyond the specific operational and clinical aims appeared to result from the collaborative. Firstly, there appeared to be increased collaboration between EDs with regard to comparing processes and opportunities for improvement. Regular communication, either directly or through the Project Director, allowed institutional comparisons to occur along with a free exchange of ideas and information. Participants also learnt new methods for overcoming barriers to change and influencing change across the organization. There was significant degree of learning with regard to pragmatic measurement as opposed to scientific research, i.e. that is it is necessary to collect only a small amount of data to measure major operational or clinical change.
Discussion
This project was undertaken during a period of near crisis in the health system in Victoria caused by the worst access block for emergency patients recorded in Victorian hospitals. In fact, the support of the Minister and DHS was probably contingent on concerns arising from this situation. In this environment, it is surprising that emergency department workers participated in a project that seemed to be an additional workload to the normal routine emergency work. Interest by the Minister and DHS certainly provoked strong executive support. It is important to note that the collaborative was not intended to improve access block directly, but rather to help EDs manage the consequences of overcrowding.
Clinical projects generally resulted in the most successful outcomes. There appeared to be less success in the operational projects and this may have resulted from the overwhelming operational difficulties being experienced by hospitals during this time. It may also reflect the attitudinal difference of clinicians to operational targets as opposed to clinical targets. Other projects have identified the need to use improvement in clinical outcome as a method for ensuring clinician interest.
Initially, there was considerable cynicism regarding the use of the Breakthrough Series as a ‘branded’ package of interventions to change hospital practice to accepted best practice. Many felt that if the evidence existed, then clinicians should just implement changes. There is now a large body of evidence to suggest that even where clear evidence exists to promote a change in practice, it does not happen automatically [10]. The Australian National Health and Medical Research Council has recognized this by funding projects designed to promote clinical practice based on best evidence, and the Cochrane Collaboration owes its existence to this phenomenon. The packaged series of steps in the Breakthrough Series towards a particular process change recognizes that there are usually a series of specific impediments that are common across institutions. Once these are identified and rectified, implementation can be achieved. The team accountability and reporting along with hospital-wide support (through executive sponsorship) are essential. Although the nomenclature and corporate style branding are contrary to Australian culture, the specific components of ‘Breakthrough’ as a program helped participants to achieve important changes. It is not clear from our experience whether it is possible to obtain similar results by using components of the Breakthrough Series. For example, the DHS could establish a body that dispensed information on projects such as how to reduce analgesic time. In our view, the structured approach, collaboration, and reporting requirements seemed to be as important as the information dispensed.
A further result of the collaborative was the realisation by staff that clinical staff could make changes happen rapidly. This was particularly the case with nursing staff. Illogical restrictions on nursing practice, such as not being allowed to write X-ray slips or initiate routine blood tests as part of a clinical pathway, were identified and artificial barriers removed. To argue the case for change, executive sponsorship and institution-wide involvement were necessary. Comparisons with other similar hospitals were also important (benchmarking).
Collaboratives in the USA have generally been self-funded by hospitals and not centrally funded, as was this one. The advantage of voluntary, self-funded participants is that they are usually enthusiastic. There was a real danger in this collaborative that the element of coercion could have destroyed enthusiasm to work for change. Although this risk was openly discussed prior to the collaborative, once the teams assembled and committed to the project, teams cooperated well.
The key components of success appeared to be good corporate sponsorship, clinician leadership, and a local clinical champion, the structure of the program (which included meeting reporting deadlines), and specific funding for the project. Significant barriers to the implementation of the project included emergency department culture (active resistance to change) in some hospitals, lack of identified leadership in some hospitals, and a change of leadership during the course of the collaborative. There were also major issues relating to data collection and IT. Many EDs had rudimentary information systems and a lack of IT support for basic functions such as tabulating and graphing information. Although teams were encouraged to work around such issues, the teams with good IT support found reporting easier.
The funding provided for this project was substantial; however, licensing fees for the IHI and for the satisfaction survey accounted for approximately one-third of the total cost. Direct payments to EDs allowed clinical personnel (doctor plus nurse) time to perform project work 1–2 days per week. This was <1% of the ED budget for those hospitals involved. It could be argued that a greater percentage of ED budget should be allocated for quality improvement projects on a continuing basis. In terms of transferring this experience to other groups, the investment per institution is small and could be justified as an investment in service improvement.
One of the aims of the Breakthrough Series is to operationalize or incorporate the changes and measurements necessary to monitor change into routine practice. Theoretically, following implementation, further resources should not be necessary to maintain change. Evaluation of the sustainability of change beyond the initial collaborative is the subject of ongoing study.
Conclusion
This project delivered a significant improvement to clinical and operational processes across 17 major EDs in Victoria and the Canberra Hospital. It also resulted in an attitudinal change at the hospitals and in the clinicians involved in the project, which could potentially allow participants to undertake further projects to facilitate change within their institutions.
Address reprint requests to Peter Cameron, The Chinese University of Hong Kong, Accident and Emergency Medicine Unit, Room 113, Trauma and Emergency Centre, Prince of Wales Hospital, Sha-tin, N.T., Hong Kong. E-mail: peter.cameron{at}cuhk.edu.hk 
Accepted for publication August 2, 2002.
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