scholarly journals MP28: Reigniting improvements in emergency departments – New approaches to resolving unsolvable problems

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S52
Author(s):  
N. Barclay ◽  
J. McDuff ◽  
M. Vanosch ◽  
L. Bournelis ◽  
S. Finamore
Keyword(s):  
Change Management ◽  
Emergency Departments ◽  
Best Practice ◽  
Standardize Patient ◽  
Management Approach ◽  
Patient Access ◽  
Model Of Care ◽  
Left Without Being Seen ◽  
Pdsa Cycle ◽  
Triage Time

Background: In 2016 The Fraser Health Authority's Emergency Network established a priority to standardize patient access and flow through their 13 emergency departments (ED). A Model of Care (MOC) was developed after an extensive review of the literature and current practices across BC. Aim Statement: The ED Model of Care (MOC) specifies best practice expectations with respect to emergency patient access and flow. Rather than a ‘top-down’ mandate of expected practices, the MOC provided the opportunity for site-based teams to promote solutions that were ‘locally actioned and regionally enabled’. Measures & Design: ED Quality Improvement (QI) teams were developed at all sites. The ED Network developed a “QI Bootcamp”, a one-day course focused on imparting tools to drive improvements, providing a baseline understanding of how to launch and sustain local QI initiatives. Using Prosci's change approach, an emphasis was placed on using local ingenuity to implement plans, analyze feedback and diagnose gaps. This approach measured utilization of the changes to tangibly link initiatives and change to specific outcomes. As part of this strategy, an online scorecard was created to measure local results against best practice outcomes. The scorecard tracked quantitative access metrics such as ED Length of Stay (EDLOS), Left Without Being Seen rate, and triage time. Measures such as forming a QI team, identifying a QI project and completing a PDSA cycle were included in the scorecard Evaluation/Results: The MOC change management strategy was launched in May of 2018. By December 2018 all 13 EDs had formed a local QI team and identified a project. Twelve sites had completed at least one PDSA cycle and 10 sites had at least 75% of their members attend the QI Bootcamp. The scorecard displayed improvements in flow metrics. Highlights include the average arrival to triage time decreasing by 36% at one site, EDLOS for moderately ill patients decreased from 4.8 to 3.4 hours at another, and a community hospital had low acuity patient EDLOS decrease from 3.52 to 2.37 hours. Discussion/Impact: A standardized approach to patient access and flow in the ED (MOC), combined with the engaging grass roots approach to inspiring local innovation, allied with a concrete change management approach demonstrated significant results for patients accessing and moving through EDs. This pattern that is more likely to sustain itself because the results are felt and locally owned.

scholarly journals Gender Equality in Business Action: A Multi-Agent Change Management Approach

2021 ◽  
Vol 13 (11) ◽  
pp. 6209
Author(s):  
Leire Gartzia
Keyword(s):  
Change Management ◽  
Gender Equality ◽  
Social Action ◽  
Basque Country ◽  
Management Approach ◽  
Private Firms ◽  
Agent Collaboration ◽  
Multi Agent ◽  
And Gender ◽  
Corporate Social

Critical to social sustainability and organizations’ growth, at present, is gender equality. Yet, egalitarian principles are difficult to apply in the practice, particularly in private firms. Acknowledging previous calls that research should respond to these concerns and support practitioners, we provide a theory-grounded conceptual framework to address change management in this field, aimed at providing applicable guidelines in the organizational practice. Integrating utilitarian and social justice perspectives about gender action, we call for multi-agent collaboration involving coordinated action from policymakers, private firms and gender experts. We provide an overview of how public policies and legislation guide organizational action by providing key statutory norms and procedures. We then address the relevance of organizational commitment and the alignment of gender goals with the organizational strategy and decision-making, involving managers. Finally, we underscore the benefits of implementing evidence-based action based on academic and consultancy collaboration. The implementation of these principles is illustrated with a multi-agent practice developed in the Basque Country (Spain) between gender equality change agents, suited to apply academic principles to real-world organizational practices. Recommendations for gender equality and corporate social action are provided.

scholarly journals The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments

CJEM ◽  
2009 ◽  
Vol 11 (05) ◽  
pp. 455-461 ◽  
Author(s):  
James Ducharme ◽  
Robert J. Alder ◽  
Cindy Pelletier ◽  
Don Murray ◽  
Joshua Tepper
Keyword(s):  
Health Care ◽  
Nurse Practitioners ◽  
Emergency Departments ◽  
Patient Flow ◽  
Physician Assistants ◽  
Wait Times ◽  
Care Providers ◽  
Lengths Of Stay ◽  
Left Without Being Seen ◽  
The Impact

ABSTRACT Objective: We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs). Methods: We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status. Results: Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3–2.1, p < 0.05) and 2.1 (95% CI 1.6–2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%–39.0%, p < 0.01) and 48.8% (95% CI 35.0%–62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%–63%, p < 0.01) and 71% (95% CI 53%–96%, p < 0.05), respectively. Conclusion: The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

Management of Ground Movement Hazards: An Overview of a JIP

2020 ◽  
Author(s):  
Yong-Yi Wang ◽  
Don West ◽  
Doug Dewar ◽  
Alex Mckenzie-Johnson ◽  
Steve Rapp
Keyword(s):  
Best Practice ◽  
Major Elements ◽  
Ground Movement ◽  
Management Approach ◽  
Hazard Management ◽  
Ground Movements ◽  
Strain Design ◽  
Hazard Avoidance ◽  
Actual Field ◽  
Girth Welds

Abstract Ground movements such as landslides, subsidence, and settlement can pose serious threats to the integrity of pipelines. The consequences of a ground movement event can vary greatly. Certain types of ground movements are slow-moving and can be monitored and mitigated before a catastrophic failure. Other forms of ground movements can be difficult to predict. The most effective approach could be hazard avoidance, proactive means to reduce strain demand on pipelines, and/or building sufficiently robust pipeline segments that have a high tolerance to the strain demand. This paper provides an overview of a Joint Industry Project (JIP) aimed at developing a best-practice document on managing ground movement hazards. The hazards being focused on are landslides and ground settlement, including mine subsidence. This document attempts to address nearly all major elements necessary for the management of such hazards. The most unique feature of the JIP is that the scope included the hazard management approach often practiced by geotechnical engineers and the fitness-for-service assessment of pipelines often performed by pipeline integrity engineers. The document developed in the JIP provides a technical background of various existing and emerging technologies. The recommendations were developed based on a solid fundamental understanding of these technologies and a wide array of actual field experiences. In addition to the various elements involved in the management of ground movement hazards, the JIP addresses some common misconceptions about the adequacy of codes and standards, including: • The adequacy of design requirements in ASME B31.4 and B31.8 with respect to ground movement hazards, • The adequacy of linepipe standards such as API 5L and welding standards such as API 1104 for producing strain-resistant pipelines, • The proper interpretation of the longitudinal strain design limit of 2% strain in ASME B31.4 and B31.8, and • The effectiveness of hydrostatic testing in “weeding out” low strain tolerance girth welds.

Using a health improvement methodology to standardise leg ulcer management

2020 ◽  
Vol 25 (Sup9) ◽  
pp. S20-S25
Author(s):  
Kirsten Mahoney ◽  
Wendy Simmonds
Keyword(s):  
Clinical Practice ◽  
Patient Outcomes ◽  
Best Practice ◽  
Leg Ulcer ◽  
Health Improvement ◽  
Evidence Based ◽  
Leg Ulcers ◽  
Venous Leg Ulcers ◽  
Poor Patient ◽  
Pdsa Cycle

Despite guidelines, best-practice statements and CQUIN targets, venous leg ulcers have been highlighted as an area that continues to demonstrate lack of evidence-based practice and variation in practice, which contribute to poor patient outcomes and escalating costs. Leg ulcer services that use a systematic and standardised approach to leg ulcer management are highly successful in improving healing rates, preventing recurrence and contributing to patients' wellbeing. This article seeks to explore the use of the plan-do-study-act (PDSA) cycle in clinical practice to improve and standardise leg ulcer management.

scholarly journals P149: Benign headache management in Alberta emergency departments: a chart review study to explore gaps in practice

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S118
Author(s):  
J. Gouda ◽  
N. Runham ◽  
L. Krebs ◽  
S. Couperthwaite ◽  
B. Rowe
Keyword(s):  
Emergency Departments ◽  
Chart Review ◽  
Medication Management ◽  
Pain Scale ◽  
Geographic Region ◽  
Care Physician ◽  
Left Without Being Seen ◽  
Personal Transportation ◽  
Study Sites ◽  
Tension Management

Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.

Implementation of project change management best practice in different project environments

2009 ◽  
Vol 36 (3) ◽  
pp. 439-449 ◽  
Author(s):  
Yi Zou ◽  
Sang-Hoon Lee
Keyword(s):  
Change Management ◽  
Construction Industry ◽  
Construction Projects ◽  
Best Practice ◽  
Change Orders ◽  
Project Outcomes ◽  
Construction Industry Institute ◽  
Project Characteristics ◽  
Project Data ◽  
The Relationship

Change orders are ubiquitous in construction projects, and effective and efficient control of changes is critical to project success. There have been many empirical suggestions as to how to manage changes for best project outcomes, but this research is specifically aimed at exploring the relationship between project characteristics and the implementation of project change management best practices (PCMBP). Construction project data for this research are derived from the Construction Industry Institute (CII) benchmarking and metrics (BM&M) database. Binary logistic regressions and factorial analysis of variance (ANOVA) are performed to find out the differences among diverse types of projects in terms of the extents to which the PCMBP elements have been implemented. The findings can assist construction industry practitioners with using PCMBP more purposefully in accordance with specific project characteristics so that they will be better able to develop and administer their project execution plans.

Best Practice for Family-Centered Health Care

2017 ◽  
Author(s):  
Joanna Sturhahn Stratton ◽  
Katherine Buck ◽  
Allison M. Heru
Keyword(s):  
Health Care ◽  
Family Involvement ◽  
Best Practice ◽  
Model Of Care ◽  
Patient Centered ◽  
Step Model ◽  
Essential Components ◽  
The Family ◽  
Centered Care ◽  
Family Centered

The patient-centered medical home is a strong model of care that can be improved by harnessing the power of the patient’s family. This chapter highlights a three-step model of family involvement in patient care: (1) family inclusion, (2) family education and support, and (3) family systems therapy. The model is grounded in evidence-based research and incorporates the essential components of integrated care. A clinical case example illustrates how to involve the family in a stepwise progression. This model of family-centered care is applicable in any health care setting.

35 Enhanced Service Through An Integrated New Model of Care in A Buckinghamshire Care Home

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i9-i10
Author(s):  
U Okoli ◽  
S Chimhau ◽  
B Nagyova ◽  
A Sahni ◽  
S Amin ◽  
...  
Keyword(s):  
Best Practice ◽  
Adverse Drug Events ◽  
Hospital Admissions ◽  
Care Home ◽  
Cost Savings ◽  
Care Homes ◽  
Multiple Chronic Conditions ◽  
Model Of Care ◽  
Nice Guideline ◽  
Care Plans

Abstract Introduction Care home residents often have multiple, chronic conditions and are receiving complex treatment regimes. Polypharmacy and medication errors are common. The frequency and quality of medication reviews is variable with limited general practice (GP) capacity to carry out comprehensive reviews. The initiative used a care home pharmacist, technician, geriatrician and GPs to tackle these issues on an individual and care home level. The objective being to ensure the safe and effective use of medicines for all care home residents. NICE guideline [NG56] recommends reducing pharmacological treatment burden for adults with multimorbidity at risk of adverse drug events such as unplanned hospital admissions. A study by Dilles et al1 found adverse drug reactions in 60% of residents. Methods A new interdisciplinary model of care was delivered in a 120 bedded Buckinghamshire care home. Clinical Commissioning Group pharmacist, general practitioners and pharmacy technician reviewed medication for all residents. The most complex individuals were reviewed by the geriatrician and if needed by other multidisciplinary team members specialist. Results Overall 115 medications were stopped for 109 residents, with 31 interventions to reduce falls risk and 19 interventions on medication at high risk2 of causing admission. Total cost savings on medicines optimisation, medicines waste and non-elective admission prevented was £35,211. Residents’ care plans were updated to reflect best practice standards. Conclusions Future direction of this project focuses on system wide improvements to promote interdisciplinary healthcare professionals work in care homes. The success of this integrated model of care has enabled recurrent funding of pharmacist by the local county council and an additional 42 geriatrician sessions into Buckinghamshire care homes. References 1. Dilles T, Vander Stichele R, Van Bortel L, Elseviers M. Journal of American Medical Directors Association 2013; 14: 371–6. 2. Pirmohamed M, et al. Br Med J 2004; 329: 15–9 61.

22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i1-i8
Author(s):  
J Kingdon ◽  
H Aadan ◽  
S Husain ◽  
C Atkinson ◽  
C Thomson ◽  
...  
Keyword(s):  
Clinical Pathway ◽  
Best Practice ◽  
Nutritional Assessment ◽  
Nutritional Supplements ◽  
Alternative Methods ◽  
Fractured Neck Of Femur ◽  
Neck Of Femur ◽  
Post Surgery ◽  
Retrospective Audit ◽  
Pdsa Cycle

Abstract Background Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality. Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016). Introduction Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support. Intervention A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time. Results Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate. PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%). PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%). Conclusions The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

Behavioural Interventions in Primary Care: An Implementation Trial

2008 ◽  
Vol 27 (2) ◽  
pp. 179-189 ◽  
Author(s):  
Dan Bilsker ◽  
John Anderson ◽  
Joti Samra ◽  
Elliot Goldner ◽  
David Streiner
Keyword(s):  
Primary Care ◽  
Health Care Providers ◽  
Best Practice ◽  
Management Approach ◽  
Care Providers ◽  
Intervention Delivery ◽  
Effective Strategies ◽  
Best Practice Guidelines ◽  
Risky Alcohol ◽  
Depression Intervention

Developing effective strategies to keep health care providers' practice current with best practice guidelines has proven to be challenging. This trial was conducted to determine the potential for using brief educational sessions to generate significant change in physician delivery of mental health and substance use interventions in primary care. A 1-hour educational session outlining interventions for depression and risky alcohol use was delivered to a sample of 85 family physicians. The interventions used a supported self-management approach and included free patient access to appropriate selfmanagement resources. The study initially evaluated physicians' implementation of these interventions over a 2-month period. Physician uptake of the depression intervention was significantly greater than uptake of the risky-drinking intervention (32% versus 10%). A follow-up at 6-months posttraining (depression intervention only) demonstrated fairly good maintenance of intervention delivery. Implications of these findings are discussed.

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