Wanting to serve disadvantaged populations, Dr. Vikram Kambampati signed up for the National Health Service Corps soon after entering medical school. As a medical student, he was awarded the New York Academy of Medicine’s David E. Rogers Fellowship to participate in a health delivery research and demonstration project, evaluating how low-income African American veterans experience a mobile medical unit. During residency, he was awarded the American Psychiatric Association/Substance Abuse and Mental Health Services Administration (APA/SAMHSA) Minority Fellowship. Dr. Kambampati then served as a Staff Psychiatrist at the Federal Medical Center (Federal Bureau of Prisons), in Devens, MA. He has presented on a collaborative care model to meet the mental health needs of jails and prisons lacking psychiatrists. In January 2013, he was commissioned as an officer in the United States Army Reserves. Dr. Kambampati completed his medical degree at the University of Pittsburgh School of Medicine in 2005. He completed his residency in adult psychiatry at Case Western Reserve University/University Hospitals Case Medical Center, Cleveland, OH.
Vikram Kambampati, MD, MPH
Medical Director of Psychiatry, Commonwealth Care Alliance, Boston, MA; Major, United States Reserve, Medical Corps
Improving Quality in an Essential Hospital: A Description of Patient Flow in the Psychiatric Department
- Determine the scope of the problem of boarders at UMass Memorial Medical Center's (UMMMC) emergency mental health (EMH) unit.
- Determine the impact that inefficient discharges on the inpatient psychiatric unit has on patient flow at UMMMC.
- Assess the culture of improvement in the psychiatry department, particularly by quality of use of employee idea boards.
- Design and test a process improvement intervention: specifically, I tested whether training to medical directors, nurse managers and frontline staff would improve the quality of idea boards, a tool to promote employee engagement.
UMMMC is a tertiary care center that delivers care to low income and medically vulnerable persons in Central Massachusetts. In a changing health financing landscape, the hospital is focused on implementing a culture of improvement and increasing operational efficiencies. The psychiatry department is ripe for change and multiple inefficiencies have been noted to contribute to poor outcomes for quality and process measures. The project focuses on decreasing the long patient boarding times that patients are subjected to in the emergency department. Process observation has identified points where the operation can improve. However, to do so, the psychiatry department must adopt a culture of improvement, and engage its frontline staff in its improvement initiatives.
I analyzed a UMMMC database of every EMH and inpatient psychiatric unit encounter during calander year 2013. I observed a key operational process, attending psychiatrist work, on a weekday and a weekend morning. I interviewed staff representing different professions (nursing, mental health counselors, secretaries, occupational therapists, social workers, psychiatrists, and utilization review nurses) in the EMH and inpatient units, on a weekday and weekend. I also interviewed leaders, such as the department vice chair for clinical services, unit medical directors, and the chief medical officer of an UMMMC affiliated community psychiatry service. Finally, I observed and documented the use of idea boards as a tool for staff engagement before and after I provided training to nurse managers and frontline staff.
- The average EMH boarding time in the last 6 months of 2013 was 17 hours. Boarding time increased on Saturdays and Sundays.
- The median discharge hour from the inpatient unit was between 2pm-3pm. The lack of discharges from the inpatient unit on weekends contributed to variations in EMH and inpatient unit length of stay.
- Frontline staff frequently cited poor communication as a barrier for change. Nurse managers did not fully implement the idea board tools in their units. Leaders and managers knew the language of Lean, but did not implement process improvements that were continuous, measured, and accountable.
- After training medical directors, nurse managers, and frontline staff on using the idea board tool to facilitate employee engagement, the quality of ideas and use of the tool improved.
At UMMMC, psychiatry department staff were not prepared to take on a new process improvement project because a culture of improvement had not yet been fully in place. Process improvement is crucial to improving internal operations of essential hospitals in a time of health system change. The foundation for process improvement in an organization is adopting a culture of improvement, and with employee engagement at its core. Employee idea boards are an easy-to-use tool that can facilitate an improvement culture, but training and monitoring of the effectiveness of idea boards is necessary.
Richard Siegrist, Adjunct Lecturer on Health Care Management, Harvard School of Public Health, and Trustee, UMass Health Care
Margaret Hudlin, MD, MPH, Cheif Medical Officer, UMass Memorial Medical Center