After a breakfast meeting, I caught Brenda Vollmer’s presentation on Improving Safety Through Automation. Grand River Hospital recently installed ConnexALL to integrate WatchMate patient wandering, Siemens fire panels and Delta Controls building automation systems.
According to Brenda the implementation of ConnexALL was initiated to better align with their hospital’s patient and staff safety goals. After installation they were able to consolidate much of the management and interaction of these three event driven systems into an automated and consolidated system using ConnexALL. Specific benefits included, improved reliability, managed group notification, reduction in manual interventions, automatic alarm escalation, increased mobility (no sitting at a workstation or watching a panel), quicker decision making, and a consolidated auditing capability.
WatchMate is used for wandering, patient elopement and infant abduction. The hospital’s security is based on the premise that it’s easier to contain (a potential security situation) than retrieve, and that it’s easier to catch someone in the act than is to try to find them after the fact. WatchMate provides notification to a user at a workstation. The hospital used switchboard operators to monitor WatchMate, since they’re usually at their desks. They had to recognize the alarm, look up who to notify, and ensure that notification is made. Now, ConnexALL automatically receives alarms, notifies appropriate staff, ensures alarm delivery (including necessary automatic retry), and escalates alarm notification when necessary. (After some googling, it seems that GlobeStar integrated with WatchMate even though the product is no longer sold by the manufacturer, Xmark.)
Delta Controls monitors building boilers, air conditioning, lighting and other basic building systems. Like with WatchMate, a user at a computer display has been replaced by automated notification through ConnexALL. Also like with WatchMate, alarms are received by appropriate staff more quickly and reliably. Unlike with WatchMate, interactions and dependencies among building systems can result in multiple subsystems generating alarms on the same change in conditions — essentially duplicate alarms. The ConnexALL system analyzes these multiple alarms and filters out duplicate nuisance alarms.
The Siemens fire control panel monitors both elevators and fire alarms. The application and benefits are similar to the building systems automation system. Because ConnexALL is integrated with both the building automation system and fire control panel, alarm analysis and management takes co dependencies and interactions between the two system, consolidating alarms and reducing nuisance alarms.
Their legacy alarm monitoring solution for these three systems was custom engineered and was no longer supported by the original vendor. The system only consolidated alarms in a central location (the switchboard) but alarm notification remained a manual process. Alarm escalation was dependent on a switchboard operator monitoring alarm notification success and responses to alarms, and escalating alarms manually. And of course, if the switchboard operator was busy or not present, alarms could be missed. Because alarm management was completely manual, auditing alarm responses was difficult, at best.
A variety of notification devices were contemplated. Many wanted to use pagers, but their pagers were not two way pagers and thus could not ensure alarms were received by the device or send back acknowledgments from those responding to alarms. Many users Blackberrys, wireless phones and desk top phones. Everyone’s desk top computer also has a client application that pops into focus when an alarm condition occurs.
Grand River Hospital’s lessons learned were the importance of weekly team meetings and the proper involvement with the vendor. Due to the impact of automating (and thus changing) workflows, getting all the operational issues and changes worked out and agreed to prior to implementation is essential. In their case, the Facilities department didn’t want to be responsible for alarms, they liked having the switchboard having this responsibility. Once they understood that ConnexALL would automate the alarm process they were agreeable. Issues like this are important to work out as early in the process as possible.
They ended up having to reconfigure their building automation and fire control systems during the implementation. They didn’t realize that a comprehensive assessment of alarm notification would result in decisions to optimize the other systems to improve overall processes.
Susan Bisaillon, with Trillium Health Centre leveraged ConnexALL for a house-wide process reengineering effort in a hospital new-construction project, the West wing project. The new wing is designed for decentralized care, rather than the conventional large central stations on large nursing units (30-40 beds). The new wing has 12 bed pods, 3 pods per floor. Each pod has what is effectively a mini central station, with more technology at the bed side. Computers on wheels located outside patient rooms are used by staff rather than workstations at the pod, or mini central stations. This minimizes time at the central station and provides caregivers more time at the bedside.
The underlying concept driving the design and implementation of the new West Wing was patient centered care. A big part of this was leveraging technology to realize a more patient centric view. The existing hospital has stand alone (that is, not integrated) wireless LAN, phone system and nurse call. The new building has combined wireless VoIP phones and wireless LAN from Cisco, and the nurse call is Rauland-Borg — both are integrated using ConnexALL.
In a decentralized nursing environment, relying on the central station as a hub for workflow automation does not work — there is no central station, and nurses spend little time at the decentralized pods that replaced central stations. As a result, workflow changes included the move of nurse call from central stations to calls dispatched by ConnexALL directly to the caregiver’s phone that is responsible for that patient.
They evaluated Ascom, Blackberry, Vocera and Cisco 7921 phones. They had a cross functional team evaluate the phones. The evaluation was accomplished in a two day beauty contest. There were 60 participants, 6 two-hour sessions where vendors presented their solutions and how they would perform in specific scenarios. The hospital chose the Cisco 7921 IP phone.
Interestingly, while the Blackberry was a popular device among caregivers, the hospital could not justify the monthly cellular bill that came with them. Until Research In Motion, the maker of the Blackberry, figures out a distribution channel for enterprise Wi-Fi deployments, they will see limited adoption in hospitals.
The hospital ultimately chose to support 2 devices: Blackberry and the 7921 Cisco handset. The carrier cost of the Blackberry was the barrier to adopting this device for the nurses. They use a plastic sleeve on the Cisco phones to improve ruggedness, make them easier to clean and protect the plastic from the detrimental effects of disinfectants. (After the presentation, there was some discussion about the potential for an increased risk of infection from the phone sleeves, an issue that will require more study.)
Besides the integration of their nurse call with the new phones, ConnexALL also drove large automated displays that replaced manual white boards to reflect patient status, staff assignments, attending physician, etc.
Trillium did a pilot to ensure integrations worked and were configured properly for optimal workflow. The pilot served as a major shake out for the wireless LAN. There were a lot of wireless LAN issues. The wireless LAN was engineered for wireless data. The addition of wireless VoIP represented a major change in performance requirements for which the initial network was not designed.
Not surprisingly, they found they had to reengineer their wireless LAN to realize sufficient performance for their new application. After initial problems during the pilot, their Cisco VAR (value added reseller), FlexITy, did a comprehensive site survey and revised the wireless LAN (upgrading existing access points, adding and moving access points) to achieve the required performance. There are presently no medical devices on the wireless LAN. The issue for them is, “what devices need to be wireless to facilitate patient centered care?” And when the time comes, the hospital will be well served to review the specifications for any wireless medical devices, do another site survey, and reengineer their network as needed — before the pilot.
Nurse managers on each unit are responsible for developing a process for managing, deploying and retaining wireless devices. So far only one Blackberry has disappeared. Another customer in the audience noted that they’d lost 30 phones out of their ED. While many of these phones don’t work outside the facility, they can be sold on eBay and other places.
A lot of effort went into preparing the staff in the new units for the differences in the care environment (especially no central stations), the new workflows, and new devices — automated display panels, phones, COWs, etc. Human factors engineers were also brought in to ensure proper body mechanics.
With the implementation of more direct and efficient communications, Susan noted increased communications between patients and the interdisciplinary team. ConnexALL is used to integrate messaging to caregivers assigned to individual patients, backup caregivers, and MET team for responding to patients with a deteriorating clinical condition.
The new technology has created a more quite care environment. Communications, nurse calls and alarms are communicated directly to the responsible caregiver without disturbing patients and coworkers. Patients have noted the more quite environment, and are complimenting nurses at a higher rate than in the existing hospital units.
Susan notes that they’re still on the learning curve with ConnexALL and working with mobile technology. Staff is still making some adjustments to the decentralized care delivery model. Staff sometimes feel isolated, especially at night.
Throughout the project hospital leadership was very supportive, a critical success factor according to Susan. All the vendors involved collaborated effectively. The planning and implementation teams met weekly to discuss strategy, planning and evaluation.
Loookin to the future, they want to integrate telemetry and their PBX. The next big project is to retrofit the units in their existing hospital. Those units will retain their central stations, but they will use the same technology as was deployed in the West wing. Longer down the road, they’re working on EMR adoption and broader more comprehensive workflow automation.
Farrah Hirji with Markham Stouffville Hospital spoke on The LEAN Evolution at Markham Stouffville Hospital: Transforming Care. After an introduction to LEAN fundamentals, Farrah launched into the application of LEAN at her hospital and the results they have realized. Their hospital was built to serve about a population of 100,000 but they serve almost double that.
Their incentives for embarking on LEAN were a rapidly growing population (24% in past 3 years) and the resulting need to improve throughput, and also the need to improve patient safety and outcomes.
Culture change is required for success with any focused process reengineering methodology. LEAN is a continuous quality improvement methodology that identifies and eliminates muda (Japanese for waste) in processes. Muda is any activity that uses resources without creating value. Most importantly, it is the patient that defines value.
The major tools are the process, implemented with people, post-it notes and butcher paper to do affinity grouping and process documentation to document the initial state. From this a value stream analysis is done that results in a strategic improvement plan. These tools are used within a specific framework called a Kaizen. A Kaizen event is a 7 week cycle centered on a major 5 day Kaizen event. The first day of the Kaizen documents the current state. Day two does rapid experiments considering process and workflow changes. Day three is focused on defining implementation changes. Day four is centered on trails and testing and creating standard work. The last day is a review and briefing the rest of the hospital staff.
Markham Stouffville targeted the ED for their first LEAN project. Their initial changes included the creation of a Rapid Assessment Zone, EMS protocol, and volunteer greeter. The result of these changes reduced triage to physician assessment interval, reduced ED LOS, and fewer patients left without being seen. In Canada, ED wait times are publicly reported, and these changes have helped the hospital meet their provincial performance targets.
Success factors: a balance of top down and bottom up innovation, collaborative leadership, and treating front line staff as the experts in the work being done. LEAN and Kaizen are cross functional teams, and this process creates the expectation of the need to change — sort of a built in change mangement process. They’ve also adopted the “Vegas” rule: whatever’s said in the Kaizen meeting, stays in the Kaizen meeting. A further technique, the “Gemba” walk takes the team to where the actual work is done and places them in the patient’s perspective. They can also see what their colleagues in different roles have to deal with and how they get their work done.
Typical change in health care takes 6 to 18 months. LEAN results in a much quicker time line, with immediate measurements of results to optimize and reinforce the positive change. The challenge is of course, resistance to change. People also ask why front line staff are making the changes. Hospital’s traditional silo organizational structures are also a barrier. Front line managers need to understand how to manage in a LEAN environment; they no longer call all the shots, but faciliate a broader group process for planning and realizing positive change.
The requirement to collect real time data to measure initial states and documents the impact of changes is a big issue. Without operational data, the LEAN process can’t analyze the current state, nor test and verify that new processes are an improvement. Finally, some operational data is needed going forward to ensure that reengineered processes don’t slip back into the comfortable old way of doing things.
LEAN thinking needs to be integrated into everyday patient care.
Farrah next laid out how to get started in LEAN process. The first things needed are a change agent and lever. This is typically a new requirement imposed on the department or oganization. An executive sponsor is also critical. This is someone who will provide appropriate commitment and “head banging” when required. Physician involvement is important, if difficult to achieve. Use an external consultant to facilitate the initiation of the project. Sustaining positive change is key; follow up meetings and audits are essential to sustaining change. Steal shamelessly from other organizations who have dealt with similar problems or implemented interesting innovations. Develop a long term strategy for transforming your organization.
Brent Maranzan from Thunder Bay asked about gaining physician involvement. Brent presented on Monday, describing how they improved OR workflow. Farrah described a couple of techniques. First she nicely but persistently asked for physician involvement. The catalyst for physician involvement in her project was letting physicians know that improved ED throughput would allow them to see more patients, and thus increase their income.
Getting started in LEAN: a very few hospitals have the luxury of their own process improvement department. At Farrah’s hospital, senior management wanted to try the LEAN methodology. Farrah also had a personal interest in LEAN techniques and was quickly drafted to lead this effort. LEAN process improvement is only part of Farrah’s full time job. Their hospital heavily relies on line staff to implement the LEAN process.
Markham Stouffville is not a GlobeStar customer; Farrah was invited to present based on GlobeStar’s recognition of the necessity of changing workflow to realize operational improvements — whether facilitated by technology or not.
As the conference came to an end, several thoughts came to mind. Messaging middleware deployments are usually point to point types of purchases. They’re focused on a small portion of the organization. Such systems are of modest scope, complexity and cost. The rub is that automating workflow through improved messaging is a need that spans the enterprise. Consequently, manufacturers in this market segment have enhanced their products and repositioned them as enterprise wide solutions. While they may still be implemented in a department by department or application by application fashion, an enterprise architecture is more cost effective and is easier to manage than a series of disparate messaging products.
It also struck this observer that there are several market segments targeting the point of care that may eventually merge into one market. These markets include nurse call, wireless phones, real time location systems, patient flow optimization applications, messaging middleware, and medical device connectivity. Much of the meta information used by these systems is common, and there is a frequent tussle between niche vendors as to who will control things like nurse to patient associations and patient to device associations. Workflow automation that impacts direct care, care coordination, therapy delivery and point of care diagnostic testing frequently bleeds across these niche markets, creating additional systems integration work for vendors, and additional complexities for buyers.
The challenge for vendors is to figure out the best ways to position and sell their solutions. While these solutions are highly flexible, hospitals want to buy solutions rather than tools. But when your product can be configured or implemented in many different ways, to create a variety of solutions, do you try to market each solution separately? Or is it best to offer a tool that can be used to realize several solutions?
Hospitals are even more challenged than vendors. There is almost nothing at the point of care that can be changed without impacting something else. The increasing overlap and integration between these six market segments has transformed a simple phone or nurse call decision into a broader workflow automation decision that impacts existing and future systems used at the point of care. Hospitals that don’t consider this new complexity, and think longer term will end up foregoing important workflow automation or face unanticipated costs in replacing or upgrading something they recently bought.
Of course supporting all these market segments, and more, is the enterprise network — specifically the wireless network. There is a general lack of appreciation among both buyers and sellers that wireless LANs must be designed to meet the specific requirements for the application at hand, whether it be wireless handsets, indoor positioning systems, or wireless medical devices. Some of these repeated site survey and reengineering costs can be mitigated with longer range planning. But in any event, a realization is needed that with each change in networking requirements, there must be a change in the network.
What impressed me most about the case studies presented by customers at this event, was their ability to apply the capabilities of the ConnexALL system to their operational requirements in thoughtful and creative ways. Sometimes this was done with the full support and involvement of GlobeStar Systems. More impressively, this was sometimes done by the hospital on their own.