The Exec: For a Successful Practice Redesign, Collaboration is Key

'It's never wrong to think about all the stakeholders,' says CNO Cori Loescher.

The COVID-19 pandemic certainly re-engineered patient care, but numerous other factors can precipitate change in the way care is delivered.

For Brigham and Women’s Faulkner Hospital overcrowding in the emergency department (ED) and patient boarding last year necessitated a practice redesign.

Cori Loescher, BSN, MM, RN, NEA-BC, the Boston hospital’s chief nursing officer and vice president for patient care services, spoke with HealthLeaders about how she and her colleagues from all levels collaborated to solve the overcrowding problem while continuing to provide high-quality care.

Cori Loescher, CNO, Brigham and Women's Faulkner Hospital 

This transcript has been lightly edited for clarity and brevity.

HealthLeaders: What is your definition of practice redesign?

Cori Loescher: I see practice redesign as looking at, depending on your healthcare environment, how you deliver care and what care needs to be delivered based on the population. Then, evaluating the structures in which you are providing that care and deciding that it is time to make a change and using that structure of putting the patient in the center and saying, “Things are not going as we had hoped. We have a new population, we have a change in service, we have challenges, we're not getting the outcomes we want, and we need to change the work and how we deliver it.”

HL: At what point is it necessary to re-engineer the way patients receive care?

Loescher: Certainly, the pandemic was one of them, but also when you are faced with a new clinical situation, a new patient population, or a new technology of change in what the industry is saying you should do for care. For example, you're looking at surgical patients who used to get their care in an inpatient setting and now insurers are saying this can be done outpatient, so you're going to change how you deliver or where you're delivering the care and the speed and time with which you do it.

We have looked at efficiencies, and we've needed to redesign care here because directly related to the pandemic is an explosion in inpatient population, and patients needing care. We have excess patients—we're boarding in our EDs, which everyone hears about—and we've needed to say, “How are we going to deliver care in nontraditional settings or with nontraditional providers in those areas?”

We’ve also needed to look at the work and see that this isn't the most efficient way for us to deliver care because it is taking us more time or is not allowing technology to support the clinicians who do the work, so we may be required to do redesign there.

We’ve redesigned it based on our team structures. We are delivering care with a much higher number of advanced practice providers—both PAs and nurse practitioners—but with having a much larger number of mid-level providers, we've had to redesign care and how we deliver that within our care delivery teams.

There are lots of reasons why you decide to re-engineer care, and each of them may be something that is foisted upon you: an increasing number of patients in the emergency department; failure to have behavioral health patient areas in which to discharge behavioral health patients; money and expense; and the Great Resignation, which leaves a scarcity of resources and a need to rethink how else and whom else can help us deliver care when we can't secure clinicians in many areas across the organization.

HL: How has Brigham and Women’s Faulkner Hospital addressed all these challenges?

Loescher: When we've done practice reorganization, it really involves bringing an interdisciplinary collaborative team together to talk about where's the problem and what is it that we're trying to solve? I'll use the most recent: we spent last year related to our overcrowding in our emergency department and patient boarding. We needed to redesign delivering care to patients in, potentially, hallways, because we had run out of beds. So, I put together a multidisciplinary team of clinicians—providers from our emergency department, inpatient, nursing, physicians, advanced persons in care management—to look at how we were going to develop these areas.

And then as we continued to dig deeper into this, we brought in additional stakeholders, realizing this is going to need to involve clinicians across the organization from other clinical care stakeholders who would be treating these patients to nontraditional service areas—for example, we need environmental services to clean.

It is bringing stakeholders together first at the highest level with senior leadership to conceptualize the problem and put that forward to the team, brainstorm ideas, and start to come to consensus through collaboration around what we're going to settle on. After we've evaluated and weighed out options, we need to say, “Now, who else needs to be at the table to talk about this?”

HL: What did Brigham and Women’s Faulkner Hospital settle on?

Loescher: We started with the fact that we have too many patients and they have to come up from the emergency department when we're overwhelmed and can't provide care. And we started weighing in: Can they go in many different arenas? And we decided it would be hallway spaces, but what hallways? Can we use conference rooms? Can we use vacant office spaces? We had to look at what was there and what met potential code opportunities for necessary requirements: Can beds fit into them? Can we get suction and oxygen, etc., available to those patients? Once we said, “No, it has to be in these hallways in these areas,” then we asked, “Will this fit for all of our units?” And the answer even at that was no. We needed to, again, be innovative and go back to redesign. So, on one unit, we have larger rooms, so we knew we could double up rooms, and we did. We’ve also put potential hallways under certain criteria meeting certain trigger points, so we could bring up beds, put them in halls, and decide which patients are appropriate to be put there.

HL: What are key tips you would suggest in implementing practice redesign?

Loescher: It’s never wrong to think about all the stakeholders and in this example, the immediate problem was the emergency department. If we had put just the emergency department together with that, it would have been a one-focused orientation to that group who are making choices for another person's areas, so you need to ask, “Who are the key stakeholders that need to be at the table to start to talk about this?”

At that table, it’s important to build an open mindset and a strong ability to listen to each other's issues, brainstorm things that may be completely outrageous, and listen without judgment. Then you systematically go through and vet those choices.

Another key tip is it’s important to realize testing and piloting a redesign and being willing to iterate as you learn more. And even once you've tested it and implemented it, to be willing to go back to the table and continue to improve on what you've done or what you perhaps did not anticipate was going to come forward.