AEHN: Are changes jeopardizing patient care?

New team assesses redesign initiatives

A decade after launching its programs aimed at cutting costs and improving patient care, leaders at Albert Einstein Healthcare Network (AEHN) in Philadelphia paused to question if the redesign was helping or hurting.

To find out, it created a temporary committee called Quality Watch to provide the first comprehensive evaluation of AEHN’s work redesign initiatives network wide. AEHN has always monitored quality, but at the departmental level. The Quality Watch team will take this information, analyze it, and make the appropriate changes to the redesign programs. The Quality Watch team will not replace AEHN’s existing Quality Management efforts. Instead, it will complement them.

"Most of the data are already available," says William Warfel, PhD, chairman of the Quality Watch team and associate general director of Albert Einstein Medical Center, AEHN’s flagship facility. "We don’t want to reinvent the wheel. We want to be the clearing house for available data."

Designing a flex model

The team’s leaders designed their plan of attack in-house. They could find no model to follow elsewhere.

They started by gathering a committee of 11 internal staff members who serve in positions managing clinical operations and who have been involved with various quality initiatives, including the work redesign.

AEHN hired two people, both administrators with experience in quality improvement, who will job-share the full-time position of coordinating the Quality Watch group.

The team first met in October and currently meets twice a month. Warfel says the project is slated for six months. At that time, its status will be reviewed.

The team first looked at its target areas, work redesign, which AEHN classifies according to two types, patient care delivery, and job roles. Janine Kilty, vice president for human resources for AEHN, says patient care delivery models as AEHN defines them include:

Patient-focused care.

A model in which more services are brought to the patient’s bedside and jobs are consolidated so fewer caregivers interact with the patient.

Service lines.

A model in which all people involved in one service are organized into an interdisciplinary team accountable for every aspect of the integrated services provided to patients. For instance, in a cancer service line, educators, social workers, nurses, physicians, housekeepers, nutritionists, inpatient, outpatient, and hospice services all work together to provide a seamless continuum of care.

Clinical pathways.

A model in which teams develop standard care plans or maps that show every essential step in a service delivery, including time frames and outcomes. These pathways are designed to reduce unproductive variations in care and streamline care processes. Caregivers follow this plan with adjustments to patients’ needs. They track the patient’s conformance to the plan and analyze variations to make improvements.

AEHN’s job redesign can be boiled down to two categories: flex jobs and blended jobs.

Flex jobs.

These jobs enable employees to shift from place to place to handle variable patient volume. The employee is cross-trained to move either across levels of care, such as from an inpatient cancer unit to an outpatient cancer unit, or across units such as from medical/surgical to pediatrics.

Blended jobs.

These jobs are created by consolidating several jobs into one new role. For example, AEHN created a position called a patient care associate (PCA) who draws blood, administers EKGs, and takes vital signs. Each of these jobs were formerly done by different people. The new PCA position eliminates job overlap, speeds delivery of service to the patient, and reduces the number of caregivers interacting with a patient.

Plan of attack

When the team met in October, it asked how to best analyze the effect of work redesign on patient care. It came up with the following five objectives:

• Inventory all role redesign and cross-training activity that could effect patient care.

• Review training curriculum and employee orientation associated with the work redesign.

• Collect quality data related to actual tasks that have been reassigned.

• Analyze available information to identify any problem areas. The team is still discussing what data it will analyze, but some areas have been targeted, including:

— patient satisfaction measures for pre- and post-implementation, particularly, patient comments, critical incidents, and other patient-related data such as waiting times and difficulty in scheduling appointments;

— comments from physicians about their experiences and their patients’ experiences;

— incident reports;

— reviews of staffing ratios and other nursing issues subject to controversy.

• Make necessary changes or take remedial actions as indicated by the analysis of the data.

The team is compiling an inventory of the role redesigns and discussing what data to gather to best determine the effect of work redesign on patient care. The team had expected to be further along but bumped into hidden obstacles common to new projects. One of the first delays occurred when staff was tackling the seemingly simple task of compiling an inventory of the job redesigns. The meeting turned into a lengthy discussion about terminology.

"People were asking ‘What do we mean by cross-training?’ and ‘What do we mean by blended?’" Warfel says. "We had to define these terms so everyone understood what was needed before we could take the inventory."

Warfel cautions anyone establishing a similar committee to build in time for such problems.

Warfel acknowledges that the team’s processes will be hit-or-miss, but he is optimistic the team will, in the end, hit its target for one reason already proven by its redesign projects: adaptability.

"We are struggling . . . but we are willing to make changes," Warfel explains.

[Editors note: Patient-Focused Care will revisit AEHN's Quality Watch team later in the year to learn what assessment processes and measures it developed and the resulting conclusions about work redesign and its effect on patient care. For more information about the Quality Watch committee, contact Janine Kilty at (215) 456-7040.]