Nurses at the Forefront of Integration

With government regulations and reimbursement pressures, health systems are looking for efficiencies that will lead to higher quality, improved access to healthcare and lower cost. On December 1, 2015 we signed an agreement to purchase five hospitals and assume the lease of another. Over the next four months, nurses took on significant integration-related roles and responsibilities. They followed a tight timeline with key activities, deliverables, and milestones to achieve for each phase of the integration from Day 1 pre-planning, scoping, validation, finalization and execution, to post-planning. The primary objectives of Phases I (due diligence), II (Day 1) and III (stabilization) were to minimize changes to current state operations while promoting operation continuity and to limit interruptions to patient care.

Guiding principles, governance structure, roles and responsibilities, and issue escalation process were initially established. Local leaders were identified to drive requirements including addressing situations that posed imminent risk to patient safety or required immediate action to minimize Day 1 disruption. As planning progressed, Day 1 requirements were refined. Additional items were identified as Post-Day 1 and supported business performance but were not critical to patient safety and operations on Day 1. These items were documented and addressed in Phase III. Nurses collaborated to create work plans and guide team efforts. Meetings included contract negotiation; workforce recruitment; planning and deploying systems, for example, nurse scheduling, payroll and accounting; cutover plan and the need for a command center to ensure downtime procedure and operations were supported during the first week of go-live. Thereafter, weekly conference calls and site visits were conducted with all levels of leadership and staff to provide updates and answer questions.

During Phase III, specialty-specific standardized, evidence-based practice tools were created to assess clinical practice. This included assessing care of the patient (entry to discharge); evaluating practice (including but not limited to emergency, perioperative, behavioral health and critical care); practice and regulatory standards; policies; competencies; workflow; technology/equipment; resources; staffing models; and environment of care/safety. Lean methods were used including process maps to plan granular steps which allowed teams to look for waste in processes that could be eliminated. Also, fishbone diagrams to identify potential causes for issues identified in Phases I and/or II and these causes were listed on the diagram. The team utilized the 5-Why technique to drill down and identify the root cause of each problem. Once the root causes were identified, the team brainstormed potential solutions that would have the greatest impact on the problem. Solutions were prioritized using a PICK chart. This chart helped the team to identify which solution would have the greatest impact with the least amount of effort. Teams created action plans/timelines to implement improvements, strategies and best practices.

Outcomes of teamwork, communication and countless hours to plan for a smooth and effective transition April 1, 2016 included identifying, managing, and closing 330 operational items. Nursing in collaboration with information technology (IT) created, implemented and deployed one central operational command center and five satellite operational command centers for post go-live support. Operations continued to function normally with no operational issues related to transition and consistent emergency room patient volumes remained with fewer patients ‘left without being seen’ compared to baselines. Supply chain contracts increased by 1,743 and 3,400 contracts were transitioned over from one system to current. Supply chain item master increased by 30,000. New technology was deployed including an electronic medical record in 52 physician practices with 496 employees trained. Following the successful transition, we are 19,600 team members and 2,900 members physician network strong supporting 11 inpatient hospitals, 240 medical office locations, eight urgent care centers, two health parks (another under construction), 16 imaging centers, pediatric center, nursing centers, hospice and homecare.

Phase III (stabilization) included prioritization and inventory of future needs and integration opportunities including clinical practice assessment findings for a total of 243 clinical operational items. We successfully closed these items and transitioned to Phase IV (integration) and began taking a closer look at processes and structures to determine how we can most efficiently treat patients and meet our community’s healthcare needs. Over the next several months to two years, we will continue to better stabilize, plan and optimize for a truly integrated healthcare system.