Attachment C -- In-person Interview Guide 06 04 09

Improving Patient Flow and Reducing Emergency Department Crowding

Master Key Informant Interview Protocol–-Site Visit

INTRODUCTION

Thank you for agreeing to participate in this study. We anticipate that this interview will last no more than 1 hour.

The focus of our questions will be on strategies to reduce ED crowding used by hospitals participating in the Urgent Matters Learning Collaborative II. We will ask several open-ended questions that will cover your general perceptions of impact of the strategy(s) that your hospital is implementing as well as the facilitators and barriers to implementation. We will also be asking questions about your overall experience as a participant in the Urgent Matters collaborative.

Before we begin the discussion, we need to take you through an informed consent process. This is the informed consent document for our study (hand informant the form), explaining our study, and the benefits and risks to you of participating. In particular, let me make sure that you understand that:

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

 

 

1. Your participation is completely voluntary. If you do choose to stay and talk with us, you may decide to leave at any time during this interview.

2. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any reports or articles.

3. We would also like to record the interview for so that we may accurately transcribe your responses. The recording will not be used to identify you in any way. The recording will be kept in a secure location. Do we have your permission to record this conversation?

4. Do you have any questions about our study or this interview process before we begin?

Overview of Interview Topics

1. History/Rationale for Strategy Implementation

2. Introduction and Implementation

3. Barriers/Challenges to Implementation

4. Facilitators to Implementation

5. Spread and Sustainability

6. Time and Expenses

SECTION 1: RATIONALE FOR STRATEGY IMPLEMENTATION: HISTORICAL AND ORGANIZATIONAL CONTEX

NOTE: Numbers indicated in parentheses refer to the primary research question/s guiding the project listed in Supporting Statement A.

Our first set of questions concerns the rationale and organizational context for implementing improvement strategies to reduce ED crowding.

1. Why did your organization decide to implement a strategy to reduce ED crowding? What were the internal and external motivators for your organization to address this issue? (1)

Probe for the following:

• Evidence demonstrating the adverse effects of ED crowding/need to improve patient flow

• Implementation of previous strategies designed to improve patient flow - to what extent were those strategies successful?

• Success stories from elsewhere (e.g., other hospitals that participated in the Urgent Matters collaborative)

• Reputation within the community (negative press/publicity)

• Champions for improvement

2. Who was involved in decision-making about this strategy? What was the level of involvement of senior executives? Clinical leaders? Operational leaders from other areas of the hospital (e.g., inpatient)? (1)

3. Does your hospital have specific quality improvement goals? If so is the reduction of ED crowding specifically listed as one of the goals? (1)

4. Would the intervention have been implemented in the absence of your participation in this particular strategyproject? (1)

SECTION 2: STRATEGY PLANNING AND IMPLEMENTATION

Planning

1. Why did you select this particular strategy? (1)

2. Who were the key participants in the design and implementation of the strategy (e.g., the core team)? From what departments? (1)

3. What types of resources were required to support implementation? Probe for the following: staff, infrastructure, money. (2)

4. Were existing resources sufficient or were additional resources necessary? How did you forecast what was needed? (2)

5. Was there a specific budget/dollar amount allotted for this strategy? (2)

6. Would your hospital have been willing and able to send 5 people to each of 3 overnight meetings of the collaborative without reimbursement of some of their expenses? (2)Would your organization have participated in the UM Learning Network II without the $10,000 stipend?

7. How much time was allocated to staff to design and implement the strategy? (2)

8. Did you follow a specific process (e.g., change management or strategy management model) to introduce and implement the strategy in your organization? (1)

Probe for the following:

• create a needs statement that indicates what needs to be changed, how change will be measured and which tools/strategies will be implemented

• use of the input/throughput/output model of patient flow model to identify factors that affect ED access, quality and outcomes

• create metrics (key performance indicators) for tracking and monitoring patient flow and improving system performance

• institute the Rapid Cycle Change (RCC)

• create a hospital-wide patient flow team

Implementation/Introduction

1. How did the hospital’s core team communicate information/introduce the strategy to the medical and nursing staff? (1)

2. How was the strategy received by staff members who were not involved in the design and implementation? (1)

Probe: if any initial resistance was encountered ask how the core team addressed this, e.g., how they obtained buy-in from staff.

3. Did resource allocations have to change as implementation proceeded at all? (2)

4. What surprises did you encounter during implementation? (1)

5. What modifications did you have to make to the strategy as originally designed? Could you describe the types of changes you made? At what point were those changes made? (1)

6. Did staffing levels change with the introduction of the strategy? How so? (2)

7. Did you encounter any challenges regarding the process of sharing data with other members of the collaborative? (1)

SECTION 3: BARRIERS/CHALLENGES TO IMPLEMENTATION

1. What types of challengesDid you encounter any challenges has your organization encountered during implementation? Did you anticipate these problems? How were they resolved? (1)

2. What were some of the barriers to the collection of data? Which data elements were easiest/most difficult to collect?

3. Can you provide any stories of how/when youDid you encountered any resistance to this the strategy’sstrategy implementation? How did you overcome this resistance? (1)

4. In retrospect, is there anything that you would dowish you would have done differently during the implementation or planning process? (1)

5. In retrospect, are there any additional resources that you wish you had during implementation? (1)

SECTION 4: FACILITATORS TO IMPLEMENTATION

1. Are there any factors in particular that facilitated the implementation of the strategy? (If necessary, probe for use of metrics, communication protocols, multidisciplinary teams, adequate resources, staff input, IT support) (1)

2. How extensive was executive leaderships’ involvement and support for the strategy? What type of support did they provide and how effective was it? To what extent were senior hospital leaders involved in the strategies? What was their role? (1)Probe: did they remove barriers, recognize success, change policies, etc.

3. To what extent does the hospital’s board of directors focus on issues such as ED crowding and patient flow? Is the board aware of the strategy? How were they made aware? Have they offered support for it?

4. To what degree were medical staff members engaged in the strategy? What strategies/tactics were used to engage staff and create a sense of urgency/importance of implementing the strategy?

5. To what extent did the ED collaborate with other areas of the hospital (e.g., inpatient) on the implementation? Which areas/staff members were involved? (1)

What are the strongest/most promising aspects of the strategy? (1)

6. What were some of other factors that facilitated successful implementation of the strategy and improvement in patient flow?

7. Probe for the following:

8. Having clearly defined goals for the strategy and establishing specific, measurable targets early in the change process.

9. Creating metrics for measuring change and monitoring success of intervention

10. Having established communication protocols in place for promoting and reinforcing the importance of the strategy to staff at all levels, the level of engagement required for the strategy to be successful and for publicizing the strategy’s success throughout the hospital

11. Creating a multidisciplinary team

12. Involving inpatient staff in the change process to gain their perspective, expertise and collaboration.

13. Involving staff in the change process/empowering staff to make decisions to improve patient flow.

14. Having adequate IT infrastructure/support to allow efficient data collection and reporting

15. 75) If you were advising your peers who wanted to implement this intervention at another hospital, Wwhat advice would you give to other hospitals about to implement a similar strategy? (1,2)

SECTION 5: STRATEGY SPREAD AND SUSTAINABILITYMAINTENANCE OF STRATEGIES

1. Do you have any concerns about the sustainability of this strategy within the organization? What has led to these concernsDo you think the strategy will be maintained? Why do you think so? (1)

2. Do you think the strategy will continue to spreadchange over time? Have there been specific activities designed to promote the spread of improvement strategies through this modelHow so? (1)?

4. What factors do you think will be criticalfacilitate the to sustain maintenance of the strategy? (1)

5. What factors do you think may hinder the maintenance of the strategy? (1)How do you maintain momentum for long-term process improvement? (e.g. by continuing to leverage senior leadership’s involvement)

SECTION 6: TIME AND EXPENSES ASSOCIATED WITH THE STRATEGIES (Questions in this section will be sent in advance of the site visit)

We would like to generate an estimate of the cost of planning, implementing, and maintaining your patient flow improvement strategies. I will ask a series of questions regarding how much time you have spent on the strategies since November 2009, which was when the Urgent Matters Learning Network II kick off webinar was held. I would like to estimate time spent on tasks specifically associated with the UM LN II activities and the evaluation activities separately from the time spent with your team planning, implementing, and maintaining the strategies.

I will also ask you to identify any additional resources needed or expenses incurred associated with the strategies.

1. Since November, what is the total number of hours that you spent working on data submission for this project (i.e. the patient-level data submission)?

2. total number of hours that you spent preparing data to be shared with other members of the collaborative?

If the respondent cannot estimate total hours, probe for average number of hours per month. (2)

Probe for different types of data collection activities; If the respondent cannot estimate total hours, probe for average number of hours per month.

3. Since November, what is the total number of hours that you spent on activities associated with participation in the collaborative? This includes webinars, conference calls, in person meetings, and site visits? (2)

If the respondent cannot estimate total hours, probe for average number of hours per month.

Since November, what is the total number of hours that you spent planning, implementing, or maintaining the patient flow improvement strategies separate from the specific activities noted above? This includes internal meetings and other tasks associated with the strategies. If the respondent cannot estimate total hours, probe for average number of hours per month. (2)

4. Were there other individuals involved in planning, implementing or maintaining the strategies beyond those identified on the team list? (HAND RESPONDENT TEAM LIST.) (2)

5. How many hours per month do you think you will spend maintaining and monitoring the strategies going forward? (2)

6. Were there any purchases made to support the planning or implementation of the strategies? (2)

   1. If so, what were they?

   2. What was the cost?

7. Did the adoption of the strategies require the addition of new staff members? (2)

   1. If so, what new staff were added?

   2. How much of their time is devoted to the strategies?

8. Did your strategies require the transfer of any resources from other units of the hospital, for example, additional beds? (2)

   1. If so, what were they?

   2. Do you know the cost of these items?

9. Are there any additional costs associated with the strategies that have not been mentioned? (2)

   1. If so, what were they?

   2. Do you know the cost of these items?

INTERVIEW CLOSURE AND FOLLOW-UP

Before we conclude, do you have anything else that you would like to add on this topic that we have not discussed?

Thank you for your time. Your comments were extremely helpful.