Patient Flow – Adopting a Comprehensive Performance
Improvement StrategyJanet Davis, PT, MPH, FACHE
Recognized for Quality Care
Accreditations and Honors Joint Commission Nurse Magnet designation by American Nursing
Credentialing Center since 2002 American College of Surgeons Commission on
Cancer – Comprehensive Community Cancer Program
Top 10 “Best Places to Work” – by New Orleans CityBusiness
Affiliated with University of Texas M.D. Anderson Cancer Manager Program and Physician Network
PATIENT FLOW FOCUS
Feb. 9-11: IHI Real Time Demand Capacity (RTDC) Workshop
March 11: Meeting with Sr. Execs regarding RTDC opportunity
April 16: Conference Call with San Antonio Medical Center
April 23: Decision to allocate .5 FTE to patient flow strategy implementation
April 28: Initiation of Morning Bed Huddles
May 4-5: Site visit to San Antonio Medical Center
PATIENT FLOW ACTIVITIES
Daily bed huddles and executive summary Weekly action plan meetings to address
strategies in place at San Antonio Medical Center
TeleTracking ROI and Project Support Assessment of best utilization of Observation
Unit and status
“Wasted Capacity Rounds” Implementation of on-call nurses under
leadership of administrative reps (June 1)
Re-opening of SNF beds on 9 (June 3) Census Management Plan/ED Surge Metrics and data analysis
Demonstrated Improvements Reduction in PACU delays Reduction in ED LWBS Targeted efforts by Physician Advisors on
movement of patients whose beds are needed on a given day
Improved coordination among Acute and Post Acute patient flow processes
Improved communication and collaboration among unit leaders, Care Managers, and ancillary departments regarding targeted bed needs
Patients on appropriate units & levels of care
More conversations about time of day patients will leave the building
Strategies Avoid inpatients on OBS – make room for
admitted ED patients (based on criteria) awaiting beds on other units and rapid turnaround of OBS patients
Telemetry observation on Observation Unit – freeing up telemetry beds for inpatients
Pre and post procedure patients to Same Day Surgery
No PACU delays due to beds unavailable
Decrease ED delays for bed placement and LWBS
Increase unit leaders’ ownership of patient flow on their units, in partnership with Care Management
Increase communication with ancillaries re flow
Increase predictability of patient discharge days and times to optimize RTDC management of flow
STRATEGIESFlow Efficiency – Early
Discharge Flow efficiency metrics at the
microprocess level Reliable process for early
prediction of day and time of discharge
Discharge appointments Defined, reliable processes for
communication of discharge data and time to all stakeholders
MD engagement in planning early for discharge and completing required documentation including provisional discharge orders
Optimize use of TeleTracking in supporting these flow strategies
Engage ancillaries in ensuring all tests/procedures required for patient discharge (including observation patients) are expedited
Care Management Strategies/ Program
Reduce % of hospital days related to long-stay patients
Increase % of observation patients discharged in 24 hours
Evaluate physician advisor role and staffing model, competencies
Evaluate care management/social services model (service line, hours of coverage, ED, skill mix, competencies)
Care Management medical director
Post Acute & Rehabilitation Assess financial impact of
Medicare Post Acute Care Transfer policy on EJGH strategies
Efficient post-acute consult process
Create “pull” by therapies, post acute units – patient finding
Early mobilization of patientsPhysician and Administrative Intensivists Concurrent coding Address end of life issues – paid
palliative care Hospitalists with defined
expectations and accountability
Key Internal Drivers
Average Length of StayAverage Length of StayOct 08 – Oct 10Oct 08 – Oct 10
Average Length of StayAverage Length of StayOct 08 – Oct 10Oct 08 – Oct 10
Oct
-08
Nov
-08
Dec
-08
Jan
-09
Feb
-09
Mar
-09
Apr
-09
May
-09
Jun
-09
Jul-0
9
Aug
-09
Sep
-09
Oct
-09
Nov
-09
De
c-0
9
Jan
-10
Feb
-10
Mar
-10
Apr
-10
May
-10
Jun-
10
Jul-1
0
Aug
-10
Sep
-10
Oct
-10
All Payer 5.3 5.2 5.0 5.2 5.1 5.3 5.5 4.8 4.4 4.4 4.5 4.7 4.7 4.6 4.9 4.9 5.3 4.7 4.6 4.2 4.5 4.5 4.5 4.4 4.4CMI 1.49 1.54 1.43 1.54 1.45 1.45 1.50 1.52 1.48 1.45 1.43 1.47 1.59 1.48 1.47 1.49 1.51 1.53 1.50 1.44 1.47 1.47 1.45 1.48 1.52
MC ALOS 6.0 6.0 5.7 5.9 5.8 5.8 5.9 4.9 4.9 4.7 5.1 5.3 5.1 5.2 5.4 5.4 5.8 5.0 5.2 4.5 4.8 5.0 5.0 4.9 5.0MC CMI 1.63 1.70 1.55 1.69 1.58 1.50 1.64 1.60 1.62 1.55 1.59 1.56 1.65 1.62 1.61 1.61 1.58 1.62 1.63 1.58 1.57 1.59 1.57 1.60 1.66
Acute Care Admissions Excluded: SNF, PSY, GBH, RHB and Newborns
Total PACU Delay (Pt-hours)
0.0
20.0
40.0
60.0
80.0
Week #
Percent of Hours MED/SURG Beds Unavailable
0%5%
10%15%20%25%30%35%40%
Apr
-08
Jun-
08
Aug
-08
Oct
-08
Dec
-08
Feb
-09
Apr
-09
Jun-
09
Aug
-09
Oct
-09
Dec
-09
Feb
-10
Apr
-10
Jun-
10
Aug
-10
Oct
-10
Dec
-10
Boarded Hours
0
500
1000
1500
3 4 5 6 7 8 9 10 11 12 1 2
ED LWBS%
0.0%
2.0%
4.0%
6.0%
3 4 5 6 7 8 9 10 11 12 1 2
ED LOS
3.04.05.0
6.07.0
3 4 5 6 7 8 9 10 11 12 1 2
What about Lean?