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?