Improving Emergency Care and Creating New Connections

Peter Brown and Alden “Joe” Doolittle
Institute for Behavioral Healthcare Improvement

The Institute for Behavioral Healthcare Improvement is a not for profit organization (501c3) formed in 2006 dedicated to improving the quality and outcome of behavioral health care. Strategic target areas identified for early action are:
• Improvement of care in hospital Emergency Departments;
• Development of more integrated approaches to general and behavioral healthcare; and
• Improvement of access to care for children and adolescents.

Improving Emergency Department care brings into play the other strategic areas and therefore was selected after listening to providers, regulators and consumers throughout the country. IBHI has just completed the active stage of managing a Collaborative of six hospitals working to improve care for behavioral health consumers in emergency departments.

IBHI is openly patterned after the very successful Institute for Healthcare Improvement. (IHI) We have adopted many of the practices IHI has successfully used in improving care for general healthcare patients, especially the Breakthrough Series Collaborative (BTS). IBHI has a board of directors from across the nation, and is open to membership for anyone interested in the objectives of the organization. The organization expects most of its efforts to address improvements in care outside hospitals.

The Breakthrough Series Collaborative Process 1
The purpose of a collaborative is to gather a group of willing organizations to work together to make significant, not merely incremental, improvements. The process is to establish three essential ingredients to success: Will, Ideas and Execution.

• Establish an AIM: identify a specific objective acknowledged to be in need of breakthrough improvement
• Recruit a group of participant hospitals with an established Will to make change happen in their organizations
• Ownership: Identify a responsible leadership team at each participating organization

• Assemble Collaborative leadership (Co-Chairs) and faculty team; include expertise in both BTS Improvement and Content
• Change Package: develop a specific set of practices which have a documented body of evidence of their value in improving the objective; plan to make them easily accessible to participants

• Assessment: Request participants describe the current state of their system before the initial learning session with a package of preparatory activities to complete
• Learning Session: educate participants on the improvement process, and the content area in a two day Learning Session. The importance of, and process for, collecting data and sharing results and the process for testing and spreading improvements in their own organizations is stressed.
• Support: Between learning sessions, collaborative participants and faculty hold frequent telephone or web based coaching sessions to encourage and share continued efforts to make improvements. They also post data on their progress to a secure website for all the other participants to see
• Second Learning Session: Mid-point of the collaborative a second learning session sustains momentum, and adds to the store of good ideas. Improvements to date are shared, and techniques refined.
• Continued Coaching: hold frequent coaching conversations by phone or web following the second learning session.
• Sharing and Celebration: A third Learning Session is held following another six months of work to improve outcomes. Emphasis is on results achieved, lessons learned, and ways the change concepts and improvements can be spread to other parts of the organization or other organizations. Successes and challenges are acknowledged and celebrated.
• Holding the gains: Participants can elect to continue posting data on he web-site and benchmarking performance for a period of time.

Emergency Care – the weak link in the “system”
As IBHI began developing plans for projects demonstrating the potential of the collaborative model, one topic often came up as a source of concern for both providers and consumers: Care for behavioral health consumers in emergency departments. The initial expectation when IBHI was formed was to focus on issues such as outcome improvement in general, integration of care and improving care for adolescents, areas more geared to community settings. It is estimated that approximately 2 Million people seek care for behavioral health problems each year in hospital EDs. In the atmosphere of overwhelmed and overburdened EDs there is much unintended variation in expertise and training in MH/SA problems, leading to inadequate care and negative patient experience. The Emergency Department (ED) is sometimes viewed as the “early warning” system for general and behavioral health care systems which are often challenged to meet client needs. There was wide consensus on the need for improvement in Emergency care. As a result, in late 2006 after several preliminary activities it was decided to develop a collaborative in this area of hospital emergency care.

Expert Panel Established
Collaboratives, as described above, rely on a package of specific improvements identified from research and practice to improve the specific product or practice. In this case there was essentially no existing body of information to form such a “change” package. In order to create a suitable body of Good Ideas, a group of experts on the subject was convened in June 2007 and their best advice for improving the care provided and results achieved was obtained.

Tammy Powell FACHE St Anthony’s Oklahoma City Co-chair
Jon Berlin M.D. Milwaukee County Mental Health Complex
Ed Boudreaux Ph.D Cooper University Hospital
James DiNunzio, MA Gateway Healthcare, Johnston, R.I.
Oswald David RN New York City Health and Hospitals Corporation
Leon Evans Ph.D. Crisis Care Center San Antonio
David Hnatow M.D. UT Medical Center San Antonio
Darcy Jaffe ARNP Harborview Medical Center
John Kettley, MS University of Mich. Hospital
Robert Moon, MSW New York City Health and Hospitals Corporation
Ike Nnawuchi, MD Comprehensive Psychiatric Emergency Program Wash. D.C.
Charles Ray, Med Criterion Health Inc.
Susan Stefan J.D. Center for Public Representation Newton, MA
Michael Trangle M.D. Regions Hospital St. Paul, MN
Peter Brown MA IBHI
Alden (Joe) Doolittle MS IBHI
Not present due to travel or scheduling issues but part of the panel
Stuart Buttlaire, Ph.D. Kaiser Permanente MG Northern California – Co-Chair
William Anthony, Ph.D. Boston Univ. Department of Rehabilitation Sciences
Michael Allen, MD Univ. Colorado, Health Science Center
Bob Dyer, PH.D. President / CEO Criterion Health, Inc. Bellevue, WA
Kirk Jensen, MD BestPractices, Inc.
Steve Miccio, MA PEOPle Inc Poughkeepsie, N.Y
Fred Michel MD Pikes Peak Behavioral Health Care, Colorado Springs
Tony Ng MD Mannanin Healthcare LLC
Sam Tsemberis Ph.D. Pathways to Housing, New York City

The IBHI Emergency Department Collaborative
A key group of faculty for the first Collaborative was recruited. The co-chairs of the Collaborative have been Tammy L. Powell, FACHE Executive Vice President/Chief Operating Officer St. Anthony’s Hospital Oklahoma City, Oklahoma and Stuart Buttlaire, PhD, MBA Regional Director Behavior Medicine Inpatient Psychiatry & Continuing Care Kaiser Northern California
Other faculty included:
Jon S. Berlin, MD Medical Director Crisis Services, Milwaukee County Behavioral Health Division, Milwaukee, WI
David Hnatow, MD Medical Director University Hospital Emergency Center, Chief of Staff, University Health System, San Antonio, TX
Darcy Jaffe ARNP Psychiatry Director, Harborview Medical Center, Seattle, WA
Steve Miccio Executive Director, PEOPLe Inc., Poughkeepsie, NY
Susan Stefan, J.D. Center for Public Representation, Newton, MA
The Director and Improvement Advisor are Peter C. Brown and Alden “Joe” Doolittle of IBHI.

Creating a Change Package
The faculty spent significant time and effort assembling the Change Package for the Collaborative. The group recognized immediately that some improvements in outcomes could only be achieved with improvement in the connection between hospitals and outside providers and agencies. In many cases consumers are given inpatient care because no quick connection can be made to providers outside the hospital. Many studies have demonstrated the effectiveness of community care. Yet, it is often difficult to make an efficient connection to a service outside the emergency department for a consumer who is having significant problems. Despite this appreciation the planning group felt, based on information from hospitals that hospitals needed to focus on the internal process initially. The extension of the program to community connections was very important, but had to wait until the hospitals had done all they could internally.

The Change Package has a matrix of strategies and ideas for improvement, organized in groupings to:
• Increase client/patient collaboration with assessment and treatment
• Simplify and expedite assessment and disposition
• Reduce length of stay and rate of return visits
• Address the boarder burden
• Improve patient satisfaction and
• Improve workforce satisfaction and retention

Of the six categories, the first three might be grouped as ideas directed at changing the clinical processes of care; the latter three can be viewed as the objectives of these changes. The focus on consumers and staff provides a target for improvement aims. The “boarder” dilemma also warrants some discrete emphasis. The package was initially based on ideas generated by and for the Improving Care in the Emergency Departments Collaborative, sponsored over the last two years by IHI, but revised to address the ideas generated by the Expert Panel organized by IBHI in June, 2007.

Building on Will – Marketing and Enrollment
The pioneering group of Collaborators was recruited through internet mailings, word of mouth and association spread of the information. An informational conference call attracted over 100 organizations. The pioneering group included hospitals from Colorado, Louisiana, Minnesota, New York, Oklahoma and Washington. They all agreed to share data on their results and to participate in the improvement process for the 10 months active phase of the Collaborative and to share data for an additional 6 months. The initiative began with pre-work and a Learning Session in New Orleans in January, 2008. Following the meeting the group participated in conference calls to share work and results every two weeks for the next three months. A second Learning Session was held in May and Collaborators shared their efforts to date and a third Learning Session Nov 5and 6 in San Antonio. The third Session allowed for a review of progress and work toward assuring the gains are not lost. Each hospital reported improvement in their operations and encouraging response from consumers. Conference calls continued through out the Collaborative, and Collaborators shared their improvement efforts and their results.

One of the most powerful dynamics of the Collaborative process is the mutual support and friendly competition of the best sort which develops. Each team is aware they will be sharing their results with the others, and wants to be able to report good results. In addition they can call on each other for ideas, inspiration and reassurance in the often lonely process of making improvements in their operation. This process has often been shown to develop improvements well beyond the implementation of those good ideas included in the change package.

Measuring Results
The Collaborative held its final learning session in November, and continued improvement is expected beyond he end of the Collaborative in all the measures the Collaborators agreed to mutually collect. These measures of success are:
• Overall length of stay in the Emergency Department
• Length of time from door to behavioral health provider who can evaluate the consumers condition
• Number and percent of total consumers presenting who must be place in restraints
• Average amount of time consumers are in restraints
• Consumer satisfaction as measured by the portion of consumers who are highly satisfied or would be willing to recommend the service to others.
Obtaining satisfaction data has proven most difficult, but all the Collaborators have developed systems for collecting this information.

Preliminary Lessons Learned

Several things have become apparent with the development of this collaborative. When this pioneering effort began it seemed likely that improving flow would require improved connections to outside the hospital providers. However, IBHI was persuaded to make the initial focus operations within the hospital. As the Collaborative developed it became ever clearer that full improvement in ED care requires much improved connection and collaboration with community providers. Indeed, 5 of 6 participants now have some external connection as an element of their improvement plan. IBHI is prepared to help ED providers make this bridge to the community. Beginning improvement efforts within the hospital, building understanding and improving processes is an essential first step. Subsequently extending the effort to include community connections and resources outside the hospital can then occur from a more stable base.

In addition, in nearly all cases the hospitals were especially interested in dealing effectively with agitation and aggression without the use of restraints. They are also especially concerned about assessment for suicidality, dealing with children and adolescents and some fairly simple issues such as transportation systems and the need to require disrobing. In each case IBHI has worked to provide expert assistance to address the issues.

A summary of the Collaborative and its results is available at the IBHI website

For the Future
Future Collaboratives will be significantly influenced by the results of this initiative. It is already clear that much can be achieved with the collaborative process. IBHI is offering the opportunity to participate in a collaborative on improving emergency care in hospitals beginning in April of 2009, and plans to develop an expanded version including improvement of the community connection as well as the improvement in hospital based service. There will be two free information calls held January 20 and 27 to inform about the first Collaborative and the plans for then next one. (A free call but registration is required at the IBHI website.) The deadline for registration to participate in the Collaborative is March 1, 2009. Questions should be addressed to Peter Brown at

Beyond the improvement in Emergency Department Care, IBHI is preparing to offer other Collaboratives to improve care in community venues. In the last two years a wider recognition has developed of the importance of integrating general and behavioral health care for the benefit of behavioral health consumers and other health care consumers alike.

In addition IBHI plans to organize a first National Summit or Forum on Improving the Outcome of Behavioral Health Care within the next year. The opportunity is at hand for improving the environment of care and the connection of care in much more effective ways and in different venues than has been possible up to this time. IBHI is prepared and ready to help undertake this effort.

January 2009

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