BOOM, Kata, Kata: The Story of Inpatient Days Reductionmichiganlean.org/resources/Documents/Event...

BOOM, Kata, Kata: The Story of Inpatient Days Reduction

Learning Objectives:

• Connect the use of traditional lean process improvement activity to better patient outcomes in healthcare

• Equip attendees with the knowledge for how this could be applicable in their own microsystem

Intro – What is GMLOS?

• Geometric Mean Length of Stay• Length of stay according to your working DRG for how long you are

‘expected’ to stay in the hospital• CMS pays organization based on this

• 3 Lacks was over by 1088 expected days

Why??

• Increased Cost of Care• Lack of communication for plan of care• Increased length of stay compared to expected • Delays in diagnosis, interventions, assessments, proper

disposition• No standard for care team rounding• 67 patient days are spent each month waiting for discharge after

the discharge order is placedPatients want VALUE: to be taken care of in the best and most

efficient way possible

Betty was the center of our work

Promote inter-professional communication and collaboration to decrease length of stay (LOS) and excess days on 3 Lacks

5

11/19/19

The Flow of Patients

Current State

7

11/19/19

Ideal State

8

11/19/19

BOOM!!

Conduct Experimentsto get there removing one obstacle at a timeGrasp the

CurrentCondition

Establish your Next

TargetCondition

1

2

3

4

THE FOUR STEPS OF KATA

Poster 1Kata in the Classroom / katatogrow.com

Get the Direction orChallenge

Our Improvement Methodology

What is Kata?

• Rhythm of practice• Scientific thinking / PDCA• Continuous Improvement• Experimenting your way to a better outcome

Kata Cadence: Improvement Kata

12

11/19/19

Interdisciplinary team meets weekly for 1 hour to work through Improvement Kata cycle

Led by Bridget Graham, CNL on 3 Lacks

Kata Cadence: Coaching Kata

13

11/19/19

Leadership participates in Coaching Kata weekly: CNO & Director, Director & CNL

Who was involved in the work

• Frontline staff• RNs, Physicians, PCAs, Social Work, Care Managers, Rehab Services,

Pharmacy

• Leadership (Barrier Breakdown)• CNL, CNS, Manager

What is our obstacle?

20

19

18

17 17

16

15

14

13

12

11

10

9

8

7

6

5 5 5

4

3 3 3 3

2 2 2

1 0 0 1 0 1 0Behaviors Placement (SAR,

LTC)IV meds (lasix,

pain, BP, gtts, abx)Ready to go, ride

not availablePending consult

recommendationsDecision Maker Procedure (Drain,

ERCP, Thora x2, video x2, EGD, Picc

Med Titration Goals of care Pain PT/OT Eval Wean O2 Diet Advancement

Testing (VQ scan, MRI, Stress, Xray,

EEG)

Pareto -Why Can't the patient meet their GMLOS?

The Flow of Information

Standard for Inter-Professional Rounds

17

11/19/19

Standard scripting developed to achieve TH standard for IPR

Weekly and Monthly Reports

18

11/19/19

“Timecard”

PT/OT Trigger

43%

65%

80%

72%72%

89%

78%

87%82%

79%

87%

77%84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 7 Week 9 Week 14 Week 18 Week 22 Week 38 Week 54

% PT/OT Orders Placed Within 4 Hours of Trigger

Increased physician and RN communication

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Week 1 Week 2 Week 5 Week 6 Week 37 Week 45 Week 57 Week 69 Week 81 Week 94 Week 108

Verbal Communication

IM Res FM Res Hosp Goal Linear (IM Res)

Create visual for what this new process did for improved communication – siloed vs. team communication

Patients discharged earlier in the day

0

20

40

60

80

100

120

140

160

10:48 AM

12:00 PM

1:12 PM

2:24 PM

3:36 PM

4:48 PM

6:00 PM

Base

line

Wee

k 1

Wee

k 2

Wee

k 3

Wee

k 4

Wee

k 5

Wee

k 6

Wee

k 7

Wee

k 8

Wee

k 9

Wee

k 10

Wee

k 11

Wee

k 13

Wee

k 14

& 1

5

Wee

k 16

Wee

k 17

& 1

8

Wee

k 19

& 2

0

Wee

k 21

Wee

k 22

Wee

k 23

Wee

k 24

Wee

k 25

Wee

k 26

Wee

k 28

Wee

k 29

Wee

k 30

& 3

1

Wee

k 32

Wee

k 33

Wee

k 34

Wek

35

& 3

6

Wee

k 39

Wee

k 41

Wee

k 43

Wee

k 45

Min

utes

Tim

e of

the

Day

Discharge Order Written and Patient Discharged Timing

Ave.Discharge Order Written Time Ave. Patient Discharged Time Average time between patient discharged and order written

Improved Communication

0%10%20%30%40%50%60%70%80%90%

100%

9-Feb16-Feb

23-Feb2-M

ar9-M

ar

16-Mar

23-Mar

30-Mar

6-Apr

13-Apr

20-Apr

CM Notes w/ DC Plan and Transportation

% Documented Correctly

Goal

020406080

100

Baseline

Week 1

Week 2

Week 3

Week 4

Week 5

Week 41

PT/OT Compliance to Standard

PT

OT

020406080

100

May JuneJuly

AugustNov

Dec (12/6)

Dec (12/27)

Jan (1/5)

Jan (1/12)

Jan (1/19)

Jan (1/23)

Jan (1/31)

Feb (2/6)

Feb (2/14)

Feb (2/21)

Feb (2/28)

Mar (3/7)

Physician Progress Note with Template

IM

FM

Hosp

Goal

Organizational SpreadEach week, the unit was able to understand where they were at in relation to their overall goal for Excess Days using this barometer.

Tiered communication

Strategy meetingCNL MeetingUnit based improvement groupIndividual unit updatesIndividual unit coaching

The Flow of Staff

IDR RN Data

The Flow of Process

Organizational Changes

• 11 distinct process changes across inpatient nursing units (6)• Continued meetings with physician groups to maintain buy-in• Now continues to be the “way we work”, and looking forward to

new improvement

Outcomes

• Decreased Excess Days: 1.3 to 0.8 per patient• Decreased LOS:

• FY16 = 3.99• FY17 = 3.88 • FY18 = 3.82

• Decrease in excess days equates to a savings of over $250,000 per year

• Press Ganey Data

BOOM!!