Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months

Increasing ED and Hospital CapacityTop Initiatives for Dramatic Results in 6 Months

Presented byPresented byMichael B. Hill, MD, FACEPMichael B. Hill, MD, FACEP

January 10, 2003January 10, 2003

““On Our Watch”On Our Watch”Illinois College of Emergency PhysiciansIllinois College of Emergency Physicians

Page 2 of 78 2003 Confidential and Proprietary

Overview of Presentation Scope of the ProblemScope of the Problem Traditional Approach to ED CrowdingTraditional Approach to ED Crowding Key Concepts in Capacity RedesignKey Concepts in Capacity Redesign Tactical ED Capacity SolutionTactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Relationship of ED Overcrowding to Inpatient

CapacityCapacity Tactical Inpatient Capacity SolutionTactical Inpatient Capacity Solution Healthcare Change – How to Design ChangeHealthcare Change – How to Design Change


Why Don’t Hospitals and EDs Work?


Barriers to Top ED Performance Caregivers have unclear vision on how to meet Caregivers have unclear vision on how to meet

conflicting needs of emergency and unscheduled conflicting needs of emergency and unscheduled medical caremedical care

Most EDs are not set up to deal with predictably Most EDs are not set up to deal with predictably unpredictable arrival times of ED patients.unpredictable arrival times of ED patients.

Organizational culture is one in which we do not Organizational culture is one in which we do not ask for help:ask for help: Unclear when to do itUnclear when to do it Unsure who to askUnsure who to ask Variable response to requestVariable response to request


Barriers to Top ED Performance

Variable integration of ED operation with Variable integration of ED operation with inpatient delivery systemsinpatient delivery systems

Varying degrees of sophistication in defining Varying degrees of sophistication in defining operational metricsoperational metrics

ED as significant revenue driver is not ED as significant revenue driver is not articulated/understood by key constituencies.articulated/understood by key constituencies.


Key Finding Confirms Central Challenge to Hospital Capacity Issues Bottom quartile performance for key Bottom quartile performance for key

operational tasks that affect inpatient operational tasks that affect inpatient intake/discharge and ED performance:intake/discharge and ED performance: Explains heavy resource utilizationExplains heavy resource utilization Indicates unclear ownership, Indicates unclear ownership,

accountability, lack of operational accountability, lack of operational metrics, significant process and unit metrics, significant process and unit variability, and lack of backup systemsvariability, and lack of backup systems




2003 Confidential and Proprietary Page 8 of 78

Traditional Approach for Improvement

We’ll fix the ED if you give us more:We’ll fix the ED if you give us more: SpaceSpace StaffStaff Information technologyInformation technology

We can’t fix our ED due to:We can’t fix our ED due to: Demographics of our populationDemographics of our population Unpredictable volume surgesUnpredictable volume surges


Traditional Change Process Initiation Based on Tactical Initiatives

TestimonialTestimonial AnecdoteAnecdote Manager has an ideaManager has an idea Strategic initiative – rareStrategic initiative – rare


Why ED Physicians Think of Solutions as Tactical Initiatives Primary tool we use for CQIPrimary tool we use for CQI Does not require hospital leadership buy-in or Does not require hospital leadership buy-in or

approval.approval. Minimal budgeting impact.Minimal budgeting impact. Few resources to identify desired behavior.Few resources to identify desired behavior.


Major Problems with Tactical Initiatives

Leadership not brought into process prior to Leadership not brought into process prior to implementationimplementation

Not enough resources to:Not enough resources to: Develop solutionDevelop solution Communicate solutionCommunicate solution Inspect to ensure proposed change is actually Inspect to ensure proposed change is actually

completedcompleted Staff not brought into development processStaff not brought into development process No measurement systemsNo measurement systems No inspection for desired behaviorsNo inspection for desired behaviors





Team Based Care

Assign hospital and unit ownership and Assign hospital and unit ownership and accountabilityaccountability

Give tool sets and skills to owner for Give tool sets and skills to owner for successsuccess

Use multiple processing unitsUse multiple processing units Reduce set up / start timeReduce set up / start time Deliver staff consistentlyDeliver staff consistently Set up real time communication systemSet up real time communication system


Metrics Driven Management Develop operational definitions and goalsDevelop operational definitions and goals Reach agreement on expectations. Then Reach agreement on expectations. Then

hold managers and staff accountablehold managers and staff accountable Monitor data on a weekly basis – database Monitor data on a weekly basis – database

managementmanagement Give people access to the dataGive people access to the data Hard wire specific next step activities based Hard wire specific next step activities based

on resultson results


Major Problems with Metrics

Key performance indicator identificationKey performance indicator identification No defined targetsNo defined targets Acuity selectionAcuity selection Removing outlier dataRemoving outlier data Start / stop pointsStart / stop points Sample sizeSample size Ownership not identifiedOwnership not identified


ED KPIs and Owners

KPIKPI OwnerOwner

Overall LOS – Admit, Discharge, Overall LOS – Admit, Discharge, OverallOverall

Charge NurseCharge Nurse

Arrival to Bed PlacementArrival to Bed Placement Charge NurseCharge Nurse

Bed Placement to MD ExamBed Placement to MD Exam ED MD/CNED MD/CN

Lab TAT – Blood/UrineLab TAT – Blood/Urine CN/Lab SupervCN/Lab Superv

Radiology TAT – Plain/SpecializedRadiology TAT – Plain/Specialized CN/Rad SupervCN/Rad Superv

Bed Request to Patient DepartureBed Request to Patient Departure CN/House MgrCN/House Mgr


Inpatient KPIs and Owners

KPIKPI OwnerOwner

Direct Admission – Arrival to Direct Admission – Arrival to DepartureDeparture

Admit Superv/ Admit Superv/ House MgrHouse Mgr

Bed Control – Request to Pt DepartureBed Control – Request to Pt Departure BC/House MgrBC/House Mgr

Pt Intake – Bed Assigned to Pt ArrivalPt Intake – Bed Assigned to Pt Arrival CN/House MgrCN/House Mgr

Pt Discharge – MD Discharge Order to Pt Discharge – MD Discharge Order to Written to Bed ReadyWritten to Bed Ready

CN/House MgrCN/House Mgr

Housekeeping – Pt Departure to Clean Housekeeping – Pt Departure to Clean InitiationInitiation

CN/HK Superv/ CN/HK Superv/ House MgrHouse Mgr


Reduce Cycle Time

Achieving target goals by:Achieving target goals by: Moving from push to pull systemsMoving from push to pull systems Being absolutely ruthless in eliminating variation Being absolutely ruthless in eliminating variation Defining clear transition steps from each provider to Defining clear transition steps from each provider to

the nextthe next Delivering work consistentlyDelivering work consistently Defining time expectations for common task Defining time expectations for common task

completioncompletion Hard wiring triggers and backup systemsHard wiring triggers and backup systems


Push Systems – Scope of the Problem Current process owner responsible to get patient to next Current process owner responsible to get patient to next

stepstep Individual ownership encourages innovation, negotiating Individual ownership encourages innovation, negotiating

skills and rewards variabilityskills and rewards variability Variability in task accomplishment means that most tasks Variability in task accomplishment means that most tasks

are sequentialare sequential High utilization of resources required to complete tasksHigh utilization of resources required to complete tasks Predictably breaks down when busy due to lack of defined Predictably breaks down when busy due to lack of defined

back up systemback up system Almost all hospital intake and discharge systems are Almost all hospital intake and discharge systems are

“push” systems“push” systems


Pull Systems – Why We Want Them! Next Step process owner responsible to ensure patient Next Step process owner responsible to ensure patient

receives next stepreceives next step Defined expectations of other staff decreases variability Defined expectations of other staff decreases variability

and encourages consistency (“hand off”)and encourages consistency (“hand off”) Decreased variability allows parallel processes to stabilizeDecreased variability allows parallel processes to stabilize Processes keyed to Key Performance Indicators ensure Processes keyed to Key Performance Indicators ensure

consistent work effort regardless of censusconsistent work effort regardless of census Well defined backup systems can tolerate volume surgesWell defined backup systems can tolerate volume surges Top performing hospitals use “pull” systemsTop performing hospitals use “pull” systems


Learning Organization

Explicit training and orientation programExplicit training and orientation program Performance evaluation explicitly link Performance evaluation explicitly link

constituency specific behavior to key constituency specific behavior to key performance indicatorsperformance indicators


Stakeholder Loyalty

Passionate, single mindedness to customer Passionate, single mindedness to customer outcomesoutcomes

Achieve target goalsAchieve target goals



CapacityCapacity Healthcare Change – How to Design ChangeHealthcare Change – How to Design Change


We’ve Tried to Fix the ED Before And …

Bad News: Bad News: Tactical initiatives rarely create signifi-Tactical initiatives rarely create signifi-

cant overall length of stay improvement.cant overall length of stay improvement.


Even Successful Tactical Initiatives Do Not Have Great Success – The ED Perspective

Ease of Ease of SuccessSuccess ImplementationImplementation

Charge Nurse runs the EDCharge Nurse runs the ED A A DDTeam Based CareTeam Based Care A- A- DDInpatient Admission Ownership B+Inpatient Admission Ownership B+ D-D-ScribesScribes B B CCFast TrackFast Track B B CCPhysician Compensation System B-Physician Compensation System B- DDMatch Capacity to DemandMatch Capacity to Demand B- B- DDBedside RegistrationBedside Registration B- B- DDObservation UnitObservation Unit C- C- DD


Tactical Initiatives That Require Evaluation

ED Mini LabED Mini Lab Dedicated Lab PhlebotomistDedicated Lab Phlebotomist Dedicated Radiology TechnicianDedicated Radiology Technician Patient Tracking SystemsPatient Tracking Systems Additional StaffAdditional Staff Additional SpaceAdditional Space


Problems with Traditional Approach to ED Overcrowding

Most ED efforts traditionally focus on tactical Most ED efforts traditionally focus on tactical initiatives that ED has traditionally acknowledged initiatives that ED has traditionally acknowledged control overcontrol over

No single tactical initiative appears to create No single tactical initiative appears to create significant ED LOS improvement on its ownsignificant ED LOS improvement on its own

Success in reducing ED LOS or ambulance Success in reducing ED LOS or ambulance diversion appears to be related to multiple, diversion appears to be related to multiple, simultaneous initiatives that focus on defined simultaneous initiatives that focus on defined backup systems for common processesbackup systems for common processes





Is the ED the Actual Problem?

ED OvercrowdingED Overcrowding Direct Admission ProcessDirect Admission Process Critical Care Intake and Transfer to FloorCritical Care Intake and Transfer to Floor PACU Transfer to Floor PACU Transfer to Floor Surgery SchedulingSurgery Scheduling

ED crowding is actually one of several ED crowding is actually one of several symptoms of hospital inpatient capacity issues.symptoms of hospital inpatient capacity issues.





Why Is It Hard to Fix theInpatient Admission Process? – The Bad News

Inpatient admissions are inexorably linked Inpatient admissions are inexorably linked to both:to both: Inpatient discharge processInpatient discharge process Movement of patients from floor to floorMovement of patients from floor to floor

No clear ownership of any of these sub-No clear ownership of any of these sub-processesprocesses

No clear organized operations knowledge No clear organized operations knowledge base to start frombase to start from


Tactical Initiatives for Hospital Admission

Ease of Efficacy

Implementation

Roles & Responsibility• Hospital Change Nurse A C-• Unit Charge Nurse A C-

3 Bed Ahead System A C+

Key Bed Process Automation A- B-

High Census Bed Protocol B+ D

Constrain Inpatient Bed Demand B- D

Change of Shift Overrides C+ D

EDMD Admit Privileges D+ D-

Bed Control in ED D- B


Key Opportunities to Increase Inpatient Capacity–Moving From “Push” to “Pull”

Increase Inpatient Capacity Increase Inpatient Capacity Augment bed control/admission processAugment bed control/admission process Intake and Discharge Process RedesignIntake and Discharge Process Redesign Develop Metrics system to measure operational Develop Metrics system to measure operational

performance and provide feedback to staff and performance and provide feedback to staff and leadership for intake and discharge processleadership for intake and discharge process

Integration of IT for key processesIntegration of IT for key processes


Increase Capacity of Inpatient Bedsby Constraining Demand

Create dedicated outpatient area for short-stay Create dedicated outpatient area for short-stay patients and outpatient procedures, rather than patients and outpatient procedures, rather than utilizing inpatient bedsutilizing inpatient beds

Discharge patients earlier in the day in a more Discharge patients earlier in the day in a more consistent fashion to decrease discharge/ consistent fashion to decrease discharge/ admission mismatchadmission mismatch

Formal multidisciplinary rounds Formal multidisciplinary rounds to evaluate any patient in hospital to evaluate any patient in hospital greater than 15 days.greater than 15 days.


Aligning Bed Identification Process - Moving from “Push” to “Pull” System

Formalize hospital ownership of all intake/Formalize hospital ownership of all intake/discharge activitiesdischarge activities ““Hospital Administrative Supervisor”Hospital Administrative Supervisor”

Formalize unit responsibility for pre-planning “bed ahead” Formalize unit responsibility for pre-planning “bed ahead” systemsystem

Automation of key processesAutomation of key processes Bed request/notification systemBed request/notification system Hospital bed activity status with intake/discharge activity, KPIs, Hospital bed activity status with intake/discharge activity, KPIs,

and staffingand staffing Capacity simulation modeling to predict bed/staffing needs using Capacity simulation modeling to predict bed/staffing needs using

information from intake/discharge data to predict bottlenecksinformation from intake/discharge data to predict bottlenecks


Communication Systems: Real Time Notification of Work Effort and Capacity

Bed Tracking – implement a bed tracking system that Bed Tracking – implement a bed tracking system that allows bed availability status to be monitored by Bed allows bed availability status to be monitored by Bed Control and Charge Nurse with the following Control and Charge Nurse with the following notification capabilities:notification capabilities: Pending/actualPending/actual Discharge cleansDischarge cleans Open bedsOpen beds Pending discharge/transfer activityPending discharge/transfer activity Occupied bedsOccupied beds StaffingStaffing Key performance indicatorKey performance indicator


Aligning Bed Identification Process - Moving from “Push” to “Pull” System

Obtain ETA on new patientsObtain ETA on new patients Monitor time to arrival with Bed Control notification if Monitor time to arrival with Bed Control notification if

receiving unit observes delayreceiving unit observes delay Develop bed cancellation policiesDevelop bed cancellation policies Formal inpatient diversion notification systemFormal inpatient diversion notification system Bed control meeting with hard wired action planBed control meeting with hard wired action plan Pre-plan critical care and step-down transfers to floor and Pre-plan critical care and step-down transfers to floor and

telemetry removals 12 hours prior to transfertelemetry removals 12 hours prior to transfer Formalize high census protocol with defined electronic Formalize high census protocol with defined electronic

hospital and medical staff notification of desired work efforthospital and medical staff notification of desired work effort


Align Intake Process-Moving from “Push” to “Pull” System

Bed Control gives bed assignment and ETA to Bed Control gives bed assignment and ETA to receiving unitreceiving unit

Sending unit gives ETA with reportSending unit gives ETA with report Formal pre-planning prior to patient arrivalFormal pre-planning prior to patient arrival Formal greeting, order placement and order Formal greeting, order placement and order

initiationinitiation Formal monitoring and communication of new Formal monitoring and communication of new

workloadworkload


Aligning Discharge Process-Moving from “Push” to “Pull” System

Formal assignment of discharge process ownership Formal assignment of discharge process ownership for all patientsfor all patients

Formal pre-planning 2 days prior to discharge of key Formal pre-planning 2 days prior to discharge of key nurse and care coordinator discharge activitiesnurse and care coordinator discharge activities

Formalize evening pre-planning of discharge reviewFormalize evening pre-planning of discharge review Formalize time of discharge for patients and pre-plan Formalize time of discharge for patients and pre-plan

for estimated time of dischargefor estimated time of discharge Formalize patient/family communication about Formalize patient/family communication about

method and time of dischargemethod and time of discharge


Aligning Ancillary Service Process

Adjust housekeeping hours to match discharge Adjust housekeeping hours to match discharge demanddemand

Formal pre-planning of discharge activities Formal pre-planning of discharge activities with Charge Nurse for each shiftwith Charge Nurse for each shift

Preplan at least 50% of transportation needsPreplan at least 50% of transportation needs Prioritize category of “potential discharge” for Prioritize category of “potential discharge” for

lab and radiologylab and radiology


Aligning Medical Staff Work Process

Constrain DemandConstrain Demand Utilize alternative hospital source for short stay/outpatient Utilize alternative hospital source for short stay/outpatient

proceduresprocedures Discharge patients earlier in the day in a maximum consistency Discharge patients earlier in the day in a maximum consistency

fashion to decrease discharge/admission mismatchfashion to decrease discharge/admission mismatch IntakeIntake

Utilize primary contact for all incoming patients to either Utilize primary contact for all incoming patients to either Admitting or to EDAdmitting or to ED

Time/date orders legiblyTime/date orders legibly Provide ETA on new patientsProvide ETA on new patients Orders accompany patient prior to arrival on floorOrders accompany patient prior to arrival on floor


Aligning Medical Staff - Discharge Process

Standardize predischarge planning procedures and toolsStandardize predischarge planning procedures and tools Pre-plan discharges 2 days outPre-plan discharges 2 days out Formal communication on evening prior to dischargeFormal communication on evening prior to discharge

Use of “potential discharge” category for lab/radiology tests Use of “potential discharge” category for lab/radiology tests needs by 0730needs by 0730

Round by 0745 on potential dischargesRound by 0745 on potential discharges Lab/radiology test results on chartLab/radiology test results on chart Review potential discharges as first step of morning roundsReview potential discharges as first step of morning rounds

Initiate timed discharge orders prior to 0900 with Initiate timed discharge orders prior to 0900 with conditional ordersconditional orders





How to Organize a Plan to Decrease Length of Stay

No magic bullet.No magic bullet. Focus on key multiple key sub-processes.Focus on key multiple key sub-processes. Develop organized plan which includes:Develop organized plan which includes:

Resources to perform analysis, recommend Resources to perform analysis, recommend changes and then implement changeschanges and then implement changes

Communication planCommunication plan Assessment methodologyAssessment methodology Measurement systemMeasurement system


Key Reference: Diffusion of Innovations, Everett Rogers (1962, 1983, 1995)

Diffusion: the process by which an innovation is communicated through certain channels over time, among the members of a social system.

Includes both spontaneous and planned spread.

Innovation: an idea, practice, or object that is perceived as new by an individual or other unit of adoption.


Hospital Clones Diffusion Process

PhasePhase ActivityActivity TargetTarget Communication Communication StrategiesStrategies

Rapid Cycle Rapid Cycle TestingTesting

TestingTesting Early Early AdoptersAdopters

One-to-One One-to-One Watching TestsWatching Tests

MentoringMentoring Testing and Testing and ImplementationImplementation

Early MajorityEarly Majority One-to-Several One-to-Several Promotion and Promotion and VisibilityVisibility

Next Grouping Next Grouping MentoringMentoring

Implementation Implementation and Spreadand Spread

Early/Late Early/Late Majority Majority TraditionalistsTraditionalists

Many-to-ManyMany-to-Many

The “Diffusion Curve”

Percent of Staff Who Implement Desired New Change Process

0

10

20

30

40

50

60

70

80

90

100

Per

cen

t o

f S

taff

Total of 28 Constituencies in Organization

“tipping” point”


The “Tipping Point”

““The name given to that one dramatic moment in an The name given to that one dramatic moment in an epidemic when everything can change all at epidemic when everything can change all at once.” - M. Gladwellonce.” - M. Gladwell

““The part of the diffusion curve from about 10 The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of the percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often diffusion process. After that point, it is often impossible to stop the further diffusion of a new impossible to stop the further diffusion of a new idea, even if one wished to do so.” - E. Rogersidea, even if one wished to do so.” - E. Rogers


Adopter Categorization: Speed of Adoption

2% 13% 35% 35% 15%

Resistors(Traditionalists)

LateMajority

EarlyMajority

EarlyAdopters

PATMembersMentors


Successful Spread – How to Manage It

Attributes of the changeAttributes of the change Type of decisionType of decision Communication channelsCommunication channels The social systemThe social system Promotional effortsPromotional efforts Change attributes that affect adoptionChange attributes that affect adoption

Relative advantage (evidence from testing)Relative advantage (evidence from testing) Compatibility with current system (structure, values, practices)Compatibility with current system (structure, values, practices) Simplicity of the change and transitionSimplicity of the change and transition Testability of the changeTestability of the change Ability to observe the change and its impactAbility to observe the change and its impact

Variables affecting the rate of adoption


Lessons Learned

Organization leadership needs to initiate and lead Organization leadership needs to initiate and lead the change process to achieve dramatic resultsthe change process to achieve dramatic results

ED has capability to decrease LOS by 30 to 40%ED has capability to decrease LOS by 30 to 40% Inpatient cycle times can decrease up to 70%, Inpatient cycle times can decrease up to 70%,

which can reliably increase bed capacity by 10%which can reliably increase bed capacity by 10% Customer satisfaction can predictably achieve 90Customer satisfaction can predictably achieve 90 thth

percentile performancepercentile performance The ED can be defined as a significant revenue The ED can be defined as a significant revenue

driver for the hospitaldriver for the hospital


Hospital Capacity Change Initiatives Critical to Organizational Success…

…A Noble Fight Lies Ahead.“It is not the critic who counts, not the man who points out the strong man stumbled or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena; whose face is marred bydust and blood; who strives valiantly; who errs and comes up short again and again; who knows the great devotions and spends himself in a worthy cause; who, at the best, knows in the end the triumph of highachievement; and who, at the worst, if he fails, at least fails while daring greatly so that his place shall never be with the timid souls who know neither victory nor defeat.”

- Theodore Roosevelt


Opportunity for Discussion Scope of the ProblemScope of the Problem Traditional Approach to ED CrowdingTraditional Approach to ED Crowding Key Concepts in Capacity RedesignKey Concepts in Capacity Redesign Tactical ED Capacity SolutionTactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Relationship of ED Overcrowding to Inpatient


Documents

Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months