The Integrated Operations Center
(IOC)
An Operational Environment that supports teams
in providing Quality Patient Care
What is our Integrated Operations
Centre?
 Concept
 Place
 Purpose
 People
What Measurable Outcomes has it had?
 Acute patient journey - 6 hour target > 90% for 15/19 mnths – a
sustained improvement
 Cared for 875 more acute patients YTD (4% increase YonY)
while maintaining bed utilisation at 2008 levels by a reduction
in ALOS, nos. of LOS outliers and improvements in discharge
by 11 (using the transit lounge) and weekend discharges
 For the three months November to January we have been able
to successfully keep closed 44 beds at Tauranga Hospital, and
allow more staff to take annual leave over the summer/ school
holiday, an have ongoing reduced occupancy
In 2009 – 2011 we had the Perfect
Storm..
 MOH 6 Hr Target expectations
 MOH Safe Staffing Healthy Workplaces –
Care Capacity Demand Management trial
site
 Air New Zealand Integrated Operations
Centre visits
What do High Risk and High Performing Orgs
have in Common?
And need to Minimise Variance
Variance creates a productivity ‘black hole’
Risky!
-increases patient risk and
decreases quality of care
Unsatisfactory
-stressful and unsatisfactory for staff
Unproductive!
-diverts significant resource away
from frontline care
01/01/2010
10/01/2010
19/01/2010
28/01/2010
06/02/2010
15/02/2010
24/02/2010
05/03/2010
14/03/2010
23/03/2010
01/04/2010
10/04/2010
19/04/2010
28/04/2010
07/05/2010
16/05/2010
25/05/2010
03/06/2010
12/06/2010
21/06/2010
30/06/2010
09/07/2010
18/07/2010
27/07/2010
05/08/2010
14/08/2010
23/08/2010
01/09/2010
10/09/2010
19/09/2010
28/09/2010
07/10/2010
16/10/2010
25/10/2010
03/11/2010
12/11/2010
21/11/2010
30/11/2010
09/12/2010
Hospitals are High Risk Organisations with
Significant Daily Variance at the front door
Tga ED Presentations Jan-Dec 2010
180
160
140
120
100
80
60
Added with Growth in Demand..
ED Attendances
(Excl DNW)
4500
4000
3500
3000
2500
2000
TGA
1500
WHK
1000
500
July
October
January
April
July
October
January
April
July
October
January
April
July
October
January
April
July
October
January
April
July
October
January
April
July
October
January
April
July
October
January
0
Q1_2004
Q2_2004
Q3_2004
Q4_2004
Q1_2005
Q2_2005
Q3_2005
Q4_2005
Q1_2006
Q2_2006
Q3_2006
Q4_2006
Q1_2007
Q2_2007
Q3_2007
Q4_2007
Q1_2008
Q2_2008
Q3_2008
Q4_2008
Q1_2009
Q2_2009
Q3_2009
Q4_2009
Q1_2010
Q2_2010
Q3_2010
Q4_2010
Q1_2011
Q2_2011
Q3_2011
2004
2005
2006
2007
2008
2009
2010
2011
How do we achieve Safe Quality
Care even on a busy day?
 Identify causes and address constraints
 Minimise and manage variation
 Predict demand
 Match demand with capacity
Methodology of the IOC
 Operations Management Principles –
forecasting, planning, demand-capacity
matching
 Think system-wide, not silo
 Visibility of operational status
 Data-driven
 Yesterday-Today –Tomorrow
 Aiming for a Learning Organisation
• Delivering effective
services to patients
• Managing residual
variance without
compromising
productivity
• Information
SSHWP Model
4.
DELIVERING
Monitoring
•
•
•
•
•
People fit for purpose
Working systems
Smoothing variability
Information
Environment fit for
purpose
1.
FORECASTING
Patient
3.
ESTABLISHING
• Forecasting
demand
• Estimating
capacity
• Setting
organisational goals
Responding
2.
MATCHING
• Assessing resource
requirements
• plant
• people
• supply chain
• budget
IOC Roadmap
Agreement
on a
Shared
Vision
AirNZ Visits, CCDM Think
Tank, Vision Forum – COO,
DON, Medical and Nurse
Leaders, IT, DSAs, Non Clinical
Support, SIU, Allied Health,
Radiology
Agreement to jointly proceed
with IOC and CCDM project
plan and confirm membership
for governance overview for
the process of change
Resource commitment
including training and
education for CCDM members
and others.
Confirm
membership of
CCPG (Plus the
project plan)
•Set up Steering group ,
agree TOR
•Communication on initiative
to staff
•A culture change/ social
movement targeted. Confirm
change management and
communication strategy
Communication
Plan - Social
Movement /
Culture Change
The 6 IOC Work Streams
Co-location
of
Operations
Staff
Working Relationships
Face to face problem
solving
Innovation over the
cooler
Staffing units :
RMO unit
RN Bureau
Admin Bureau
Orderlies and security
Coordinator
Hospital Coordinator
Duty Managers
Emergency Planners
Forecasting
and
Planning /
CCDM
“Status
at a
Glance”
Data
Views
From data
bases TrendCare,
Webpas
Organisation wide
visibility and
understanding/
awareness
Proving to be
very accurate
IT harnessed the
data to increase
understand around
what is happening
Allows for
Evidence
based
planning and
staffing
Built within the
organisation,
cost effective
Scheduled work
visible to all
Enables early
identification of
exceptional
circumstances
Enables informed
conversations across
key groups for
problem solving
Daily IOC
Meeting
Operational
oversight
11.30am Daily
Operations
Team Meetings
- MDT, Whole
of Hospital
focus
Operational
decisions not
made in
isolation
Yesterday,
Today,
Tomorrow
Improvement
Model
SOPs
ED SOP
Developed
(Northland DHB)
Acute Patient
Journey SOP
developed
Reflects
patients location
and stage of
journey
Whole of
hospital
agreement
A live document
VRM /
CCDM
Each team
develops a VRM.
Provide
framework and
context for
escalation care
capacity
decision-making
A live document
Forecasting
 5 years of data
 Proving to be accurate
 Source, local data bases, Trendcare
 Allows for base line planning
 Staffing to need (evidence based)
 Built within the organisation, cost effective
Standard Operating Procedures -SOPs
Agreed Response Plan in advance with Front Line Staff and Service
Leaders
 Standard Operating Procedures (SOP) – Agreed Business as Usual
patient flow processes
 Variance Response Management Plans (VRM) – Essential Care
Protocol
On the Day
 SOPs used predominantly to unblock process constraints
 SOPs are developed and proposed in response to lessons learnt and
evidence from the yesterday, today, tomorrow cycle
 VRMs are used when capacity and demand move into a mismatch
Its about what's best for the patient and how the organisation can
organise capacity to best deliver this
CCDM - Matching Resource
 Mix and Match – HIA, medical floors, ED, APU
 Staffing to forecasting
 Capacity management - 3A closed, CSU open
 Medical resource in APU
 SOP
Daily Operations Meeting Date: 16/3/2012 1130.
Julie Chapman
Yesterday
Today
Fri
Sat
Sun
Mon Tue
Wed Thu Fri
6 Hr:
74% 91% 77% 87% 90% 94% 93%
ED presents fcast
118
109
131
122
120
110 105 118
ED Presentations:
121
107
111
124
118
116 104
Acute/arr ad fcast
54
32
30
56
51
59
54
Acute/arr Admits:
47
25
29
52
47
47
40
% Admitted via ED
39%
23%
26%
42%
40%
39% 35%
Elective Admits
8/3
0
2/1
12/1
10/2
7/5 13/4 2/2
Discharges fcast
64
24
20
55
56
61
56
Discharges Actual
67
32
15
51
77
63
64
Discharges Pred TC
23
9
10
14
19
22
26
26
low
14
Est. Dchges
Occ at 1100
26
92%
Learnings/ Actions
Yesterday
Good ED performance, numbers to
prediction
64
Safety Watches
Weather
fine
ED
3 in w/r.
Staffing Variance
redeployment/ SW covering within.
Sick calls x 3 so far fro pm, nasty cold
doing the rounds
Acute OT
695 mins on board. 2nd acute OT on
CT/US
12 pts waiting for CT, some OP CTs
deferred
95%
Surg CME day, therefore possible
capacity to close beds later today or
over
weekend ? 1d to close if
possible
General X ray/Fluoro
A. Health
Clerical Support
Hosp.Supp.Svcs.
Exp. Discharges
ED
Staffing Variance:
RMO
Acute OT
Radiology
A. Health
Hosp.Supp.Svcs.
Fri
Sat
Sun
Mon Tue
Wed Thur Fri
100% 100% 100% 100% 100% 98% 100%
54
RMO
Tomorrow
Whakatane
Tomorrow:
level of confidence in power board
50%. Non essential on temp board until
essential circuits moved over. Reduced
lighting/power rad/basement. No
impact CT. Next Sat 24th 0700 north
power local transformer cut to trans to
board. Outage of about 5 mins x 2 to
liven temp board B. level of confidence
then 80% Longer outage for migration
to be planned meeting next week.
St Patricks day Sat.
Flow and LOS Initiatives and Impacts










EDD on Trendcare and WardView
CNS stream in ED
Appropriate use of OBS
Increased APU capacity with chairs, APU
Reg
Allied Health Weekend Trial
Phlebotomy Rounds earlier
Transit lounge surge capacity
Acute response by IP teams
Red Triangles Ward View
Structured Daily Meetings on Ward
Nek Minute - VRM
Variance
Response
Management
What does Care Capacity Variance look like?
There is the capacity available to offer more health care to more people
The capacity is about right to efficiently provide quality care
which demands reasonable work effort
Safe effective care can be provided with extra work effort and
some change to how care is organised
The ability to provide safe care is at risk. Care is being rationed.
Resources are being diverted away from direct care and into
service rearrangement
Care and safety are being compromised. The system is gridlocked.
Resource attention is being directed at the system rather than the
care
Variance Response Management Matrix
Mauve
Green
Yellow
Exec.
Management
Service
Leadership/
Ops
Management
Ward Unit
1.The Variance status (Colours) are defined;
Mauve
Extra capacity
Green
Capacity matches demand
Yellow
Early variance
Orange
Significant care capacity deficit
Red
Critical care capacity deficit.
Orange
Red
Ward/Unit Variance Response Action Plan
Mauve
Nursing
Green
CNM/Delegate determines
plan for the shift and
communicates with Duty
Manager
CNM/Delegate determines
plan for the shift and
communicates with Duty
Manager
Expedite discharges:
Review EDD for patients’
expected to discharge in next
24hrs.
Review patient management
plans.
Expedite discharges:
Review EDD for patients’
expected to discharge in
next 24hrs.
Review patient
management plans.
Offer staff for period available
(e.g. 1 hour, 2 hour, 4 hour,
meal relief, full shift).
Escalate to medical team
any patients not seen in last
24hrs.
Staff maybe directed to area
of greater variance in cluster.
Staff maybe directed to area
of greater variance in
consultation with Duty
Manager.
Review staffing for next
24hrs.
Pull patients in from other
areas (e.g. outliers or ED)
If staff not required, consider
offering annual leave or time
in lieu (if owing).
Consider quality improvement
activities
Ensure appropriate timely
referrals to Allied Health
Review staffing for next
24hrs.
Consider capacity to ‘pull’
patients in from other areas
(e.g. outliers or ED)
Consider quality
improvement activities
Ensure appropriate timely
referrals to Allied Health
Yellow
Orange
Red
CNM/Delegate
determines plan for the
shift and
communicates with
Duty Manager.
As per Yellow plus:
Notifies Duty Manager
and requests specific
resource eg additional
staff or admit stop.
CNM take on floor coordination role.
Consider overtime,
extended shifts and/or
calling in part time
staff.
CNM considers
utilisation of all staff
present e.g. orientation
staff and students.
Ensure ward/unit MDT
are aware of status.
Consider notifying
Nurse Leader.
Put agreed care
rationing measures in
place including
rounding.
Compile activity sheets
for staff coming to
assist for short periods.
Ensure patients and
on-ward relatives
aware of status.
Reassess status in 1
hour
Complete Reportable
Event form (REF)
inclusive of Trendcare
variance.
As per Orange plus:
Mandatory reporting to
Duty Manager and,
Nurse Leader.
CNM remains on the
unit.
Consider reallocating
staff to balance skill
mix across floor
Expedite discharges:
Review EDD for
patients’ expected to
discharge in next
24hrs.
Review patient
management plans.
Escalate to medical
team any patients not
seen in last 24hrs
Repatriation of patients
to other facilities.
Identify patients who
could be put in to the
lounge to await
discharge.
Review staffing for next
24hrs.
Reassess status in 1
hour
CNM to arrange for
staff to stop all non
clinical activities, e.g.
cancel staff training.
CNM take on floor coordination role.
Implement “admit stop’
Put ‘life and limb’,
agreed care rationing
measures in place
including rounding.
Reassess status in 30
minutes
And so how does the IOC relate to the
MOH 6 Hr Target….
The IOC provides for a targeted focus on
patient flow:
 Patient flow -variation and constraints on the day
 When the planets align - 95%!!
 When they do not – we identify which planet
 Initiatives are live evidenced
 Impact of change is monitored live
Variance in the Daily 6 Hr Target
Performance
What enabled the IOC implementation?
 Having a whole of hospital shared vision
 Leadership by senior management and clinical
leaders
 Hearing concerns to the fullest and champions
addressing them
 Working hard on awareness across the
organisation – social marketing
 Proactive implementation – whole of hospital
Positive Outcomes
 Organisational ability to learn, and translate into action
 IOC operational staff report enhanced problem solving 







face to face
Conversations are informed by Status at a Glance screens scene setting
Silos reduced for operational decision making
Working in the “tomorrow” and less surprises today
SOPS - shared understanding
Variance Response - unified language using the ‘colour’
system
Transparency between departments - visual picture of the
organisation status
Timely Data Entry
Developing trust – bridging gaps
The Future
 Hospital Dashboard, Hospital Schedule,
Electronic Whiteboards
 What else would staff find useful?
 GO TEAM nominated Awards, Making Change
that Matters Competition
 Mechanism to identify Patients at Risk
 Trendcare Patient Pathways
 Awaiting VRM audit results