S

Transition Update MUHC Department of Medicine

Medical Grand Rounds

Thomas Maniatis and Joyce Pickering

Nov. 18, 2014

Outline of presentation

S Highlight transition milestones successfully completed

S Identify transition activities to be completed

S Emphasize the importance of everyone’s input and

involvement in shaping the new MUHC

S within the clinical, educational, and administrative domains

S assuming basic transition information is already part of the

collective consciousness…

Transition in a nutshell…

S The MUHC has been changing for years already…

S …accelerated pace of change coming with completion of

Glen site

S Change is the only certainty…so what is changing?

Moving places…

Moving people…

Patients (and families)

Moving people…

Health-care professionals

Moving people…

University and Hospital

employees

Shifting services

S Redistribution of clinical services has been an ongoing process for years

S eg. ortho, vascular, cardiac cath

S Pace of change increasing with Glen site completion

S eg. hem & endo shifting towards Glen

S eg. derm, allergy & immunology & rheum shifting towards MGH

S Services are being shifted based on clinical plan and recent changes

S within the Dept. of Medicine, “single site-ing” of services is relatively new and so mechanisms need to be created to ensure access to care

Shifting sands...

The “clinical plan”…

Basics: Glen Site

S 1001 Boul. Décarie

S Montréal, Québec

S H4A 3J1

S Tel.: (514) 934-1934

Inpatient

S Under the Medical Mission

S RVH and MGH General Medical CTUs

S 15 E and W, 6 and 10 Med,

S Geriatrics

S Hospitalists,

S Short Stay Units (both sites)

S CCU (both sites)

S Montreal Chest Institute (including Chest ICU beds)

Inpatient

S Not under the Medical Mission, but interacting closely:

S 7 Medical and MGH 17 (hematology/oncology)

S Palliative Care Unit

S Intensive Care Unit

General Medical CTUs

Name Current Beds Beds April 2015

15W 23 22

15E 22 22 on 17th floor in

summer, 2015

6 Med 26 26 on C9

10 Med 26 21 on D9

Proposal for a 12 bed Acute Care of the Elderly (ACE) unit on

C9

Medical Inpatients

Current Beds Beds April 2015

Geriatrics 25 on 8 Medical RVH 15 on 13E MGH

Hospitalist 24 on 7W RVH 10 bed FM run teaching

unit, D8 Glen

RVH SSU 14 10

MGH SSU 12 10

Geriatrics will move to the MGH at the end of March.

Inpatients

Current Beds Beds April 2015

MCI ward 20 16

MCI ICU 7 7

RVH CCU hot 10 14

RVH CCU cold 8 9

RVH “flyers” 6 Post Anesthesia Care

Unit (PACU)

MGH CCU hot 6 9

MGH CCU cold

7 4

20 chronic ventilator patients to Lachine in January, 2015.

Other inpatients

Current Beds Beds April 2015

RVH ICU 22 24 - 35

MGH ICU 22 24

7 Medical 16

17 MGH 15 36 at Glen

PCU 15 12 at Glen

Major downsizing

S Geriatrics – 25 to 15

S Hospitalist to Family Medicine led Transitional Care

teaching unit – 24 to 10

Timing for downsizing

S As of Jan 12th, Geriatrics and hospitalist units will stop

admitting until they are “down to size.”

S 10 Med will stop admitting Feb. 9th, until down to 21 beds.

S SSU will keep all beds open until the day of the move.

S Further decrease (about 20%) on 6 and 10 Medical the week

before the move to allow room to admit from the Glen ER -

exact number TBD.

Minimizing risk of prolonged

wait for admission in ER

S Working closely with Agence to move end of active care patients out quickly.

S Designation of Dr. Fred Dankoff as the Physician Bed Manager:

S Make quicker decisions re admitting unit for patients who do not clearly fit the admission algorithm and for use of “off service” beds.

S Facilitate transfer to community hospital when no further tertiary care required.

S Geriatrics to admit only from inpatient units, not from ER

Day of Move

S Designation of sending team and receiving team

S Double coverage for all services, including code blue, OR

S All patients will travel with at least one nurse

S Some patients will also travel with an MD.

S Resident manpower will be “centrally” managed – being coordinated through Dr. J-M Troquet and Mark Daly

S 8 hours to move all patients – 2 tracks.

Day of Move

S Rounds at 5:00 a.m.

S If patient not stable for travel, will be designated an ICU

patient for that day.

Outpatient

S Milestones achieved: Physician coverage

S translated clinical plan into actual space/time in various clinic

clusters

S Medical cluster: endo, GI, GIM, hem, hepatology, derm, allergy-

immunology, geriatrics, tropical medicine, nephrology, neurology

S Cardiovascular cluster: cardio + surgical groups

S Respiratory medicine: respiratory clinics

S CVIS-ID cluster: CVIS, ID, pre-travel vaccine clinic

S recognize teaching mission as central to our mandate

Outpatient

Outpatient

S Clerical support staff

S Identified number of clerical support needed in various clusters

S Working on cluster-specific ways of working

S patient check-in

S patient check-out, including booking of follow-up appointments *

S phone call handling

S dedicated and separate extensions for access to nursing and physicians

S groupings in development for shared resources

S Identifying clerk workspaces in each cluster

S room use

S Still working on identifying which clerks will work in various areas…

Outpatient

S Appointment and Referral Centre (ARC)

S manager identified

S draft timeline for implementation developed

S technology being fine-tuned

S phone system

S phased implementation in

S (i) time (Jan-Feb-Apr) and

S (ii) duties

S appointment rebooking and confirmation first…

S referral handling later

S staffing estimates available

S medical cluster: 2.5, resp 1, CVIS-ID 1, cardiovascular 1

Outpatient

S Nursing

S identified nursing support needed in various clusters

S addressing long-standing needs and trying to fill lacunes

S eg. dedicated sickle-cell and thalassemia nurse

S eg. dedicated OPAT nurse

S eg. complex care nurse

S eg. nursing support for expanded Medical Day Hospital

S optimizing current nursing staffing in areas with changing volumes

S transfer of activities should be accompanied by transfer of nurses and other support

Outpatient

S Challenges

S Dialysis

S Distribution of patients across MUHC

S which patients go where?

S Assigning new clerical roles to individual staff

S Waiting room management

S pager “discs”

Outpatient

S Challenges

S Shadow charts

S scanning of selected docs; integration into medical record

S Address clinical plan-induced volume reductions in some manner

S “delta” is significant for many groups: cardio, resp, GI

S physician-led building…“divestment” of patients…

S at the same time, access to outpatient specialty care remains a challenge…

S Integration of electronic charting in outpatient areas

S OWord, scanning of handwritten notes

Medical Day Hospital

S Expansion from 5 pods to 13 pods

S merger of multiple satellite day hospitals across MUHC

S Current volumes +

S endo dynamic testing

S thalassemia patients from Children’s

S benign hem from MGH

S post-transplant patients requiring infusions, etc.

S Volume analysis shows 105% occupancy based on above without changing operating hours (8am-4pm)

Medical Day Hospital

S Increased hours (8am-6pm) results in 84% occupancy with

protocolized patients

S Increased resources required

S Nursing resources are biggest need

S Clerks to support activities

S Physician presence may be needed but it will depend on number

of “investigational” patients

S Ideally great learning environment but will need time to mature…

Outpatient

S MGH

S shift of activities into polyclinic structures

S most medical clinics should move to L8

S cardio, derm, endo, GIM, hem, ID, resp

S Nephro on L5

S allergy & immunology and rheumatology should stay on A6

S GI and home TPN should be on D7

S proposal for MGH Medical Day Hospital being drafted

S temporary moves to accommodate cascades…

S meetings coming up to detail moves…

Outpatient

S How you can help:

S share your experience in outpatient areas to develop realistic

clinic workflows

S think of the patient perspective…try to improve access

The Outpatient Move…

S Move of teams, patients, and activities

S moratorium on booking appointments post-move until details

of MediVisit templates and staffing clarified *

S detailed move schedules sent out to teams

S changes being made following consultation

Sample Move Schedule…

The Outpatient Move…

S Plan for emergency clinic for outpatient activities in Dept. of Medicine at the RVH

S likely on E2

S to help deal with emergencies in April 2015 as clinics “close”

S note reductions in ER and inpatient activities as well

S Outpatient move

S planned reduction in activities before move

S to 25% of current volumes/capacity for each clinic the week before the move

The Outpatient Move…

S Patient safety is primary focus of these reductions

S Following each group’s move, teams to familiarize themselves

with new setups

S Clinics reopen on/after April 27, 2015

S please ensure clinics are cancelled in that window period

S Planned reductions in post-move volumes

The Outpatient Move…

Educational & Administrative:

Academic Workstations

S Milestones achieved:

S workstations allocated across Dept.

S on C4 (D4) and D5

Educational & Administrative:

Academic Workstations

Educational & Administrative:

Academic Workstations

S Milestones achieved:

S 1:1 ratio for MDs, RNs, hospital & university employees

S grouping generally favourable across Divisions

S equitable allocation of available closed workstations

S grouped Departmental leadership into cluster to improve collegial and shared decision-making

S promoting interprofessionalism

S 5:1 ratio for residents & fellows

S grouped together in link on 9th floor

S promoting interdisciplinarity

Educational & Administrative:

Academic Workstations

S Milestones to be achieved:

S construction of workstations in links across 7-8-9-10 at Glen

S allocation of teaching cluster on 8th floor link and grouped resident workstations on 9th floor link

S ensure actual space for research groups is aligned with assumptions

S How you can help:

S recognize limited storage space in workstations – streamline

S start thinking of adapting work style to open workstation environment

S how to assure confidentiality…

Educational & Administrative:

Academic Workstations

S MGH

S Wherever possible physician offices will be close to or adjacent

to clinical areas

S Allergy & Immunology and Rheumatology Clinics on A6 –

offices on C6

S Medical Clinics on L8 – offices on L8 or another floor nearby

in Livingston

S Nephrology Clinics on L5 – offices on L4

The Neuro

S RVH moves as of April 26, 2015

S Dedicated GIMCS for Neuro piloting as of Sept. 2014

S Coordinated consult algorithm within Dept. of Medicine

S Preliminary feedback: working well to date

Educational & Administrative:

Educational Programs

S Adapt to shifts in patient volumes

S learners should follow patients

S Ensure inpatient and outpatient programs integrate learners

S May mean important changes in learner distribution across

sites

Educational & Administrative:

Teaching Spaces

S 72 small conference rooms (6-10 people)

S 57 medium conference rooms (10-20 people)

S 44 large conference rooms (20 – 30 people)

S 1 amphitheatre (200 people)

S This excludes any conference rooms put in the links

Educational & Administrative:

Teaching Spaces

S Survey of needs for teaching space sent to programs, departments,

allied health services.

S All should “fit”

S Caveat: a number require 50-60 seats

S ? Rearranging some spaces (e.g., removing central table)

S Using link space?

S Video conferencing?

S On line central booking system to be up and running this winter

How else can you help?

Insights from the last year…

S Recognize the importance of relationships as we struggle when faced with limited resources, reducing PREMS…

S advocacy is necessary but please remember that…

S …relationships with colleagues and patients are more important than politics

S Recognize that we are all fundamentally changing how we do things are the MUHC

S be supportive of each other

S recognize we’re all incredibly challenged by all of this change

S get engaged in the process…

How else can you help?

S Participate in activities designed to commemorate the

importance of leaving the RVH

S Last Skit Night Dec. 12th

S Department is considering other events closer to the move…

S recognize the patients and health-care professionals who have

made the MUHC-RVH what it is…and have made many of us

who we are

S we will bring this uniqueness to the Glen…

Summary

S Many transition milestones have already been achieved and are behind us

S A lot of work is left to do…

S It’s not too late to participate in the process

S In spite of bumps in the road, we will form the heart of the new MUHC as the health-care professionals working there

S Unique privilege to say good-bye to the RVH and to help shape the new MUHC, including Glen, MGH, Neuro

Finding our way from here…

…to here…

…to end up?