9/15/2017 THROUGHPUT. IT S NOT JUST AN EMERGENCY DEPARTMENT ISSUE LEARNING OBJECTIVES

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1 THROUGHPUT. IT S NOT JUST AN EMERGENCY DEPARTMENT ISSUE D O N N A C R I M M I N S - B O N N E L L, B S N, M H S M, C P H Q, L S S G B LEARNING OBJECTIVES 1) Define who is affected by inefficiency in throughput 2) Identify at least 2 metrics for tracking throughput. 3) Define the cost and waste opportunities in a Throughput project METHODIST MANSFIELD MEDICAL CENTER -254 beds Community Hospital -Full Service, Acute Care -51,000 ED Visits -Dallas-Ft Worth Metroplex -Part of the Methodist Health System -10 years old -Magnet Facility 1

2 Our Throughput Team Amy Brown, RN Cardiac-Tele unit Clinical Coordinator Donna Crimmins-Bonnell, RN Quality April Greenberg, RN ED, Charge Nurse Ashlee McAdams, RN ED Manager Robyn Rankin, RN Cardiac-Tele unit Charge Nurse Vicki Wiseman, RN Director Med-Surg Stephen Griffin, Mentor Lean Sensei Background Increases in patients who left without being seen [LWOBS] and patient holds spiked in early 2016, impacting many key metrics July '15 Aug '15 Sept '15 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 In Quicker Satisfaction 91% 91% 90% 89% 89% 88% 70% 59% ED Satisfaction 79% 59% 71% 41% 21% 50% 63% 22% LWOBS LWOB % 1.7% 1.4% 4.7% 3.9% 3.1% 4.6% 5.7% 10.3% Holds-7am H.S. report MD Decision to BIB-median min Visits 4,272 4,274 4,465 4,340 3,947 4,129 4,235 4,090 Why Why is This a Problem? this a problem? Mortality increases 2.5% for patients holding in the ED up to 2 hrs. and 4.5% when holding over 12 hours LOS increased Hospital Acquired Infections Increased Med variances & missed treatment Patient experience scores Early Bed placement is KEY! 2

3 Background including the bottom line July '15 Aug '15 Sept '15 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Gross Rev Loss $85,000 $72,000 $250,000 $202,800 $145,200 $228,000 $289,200 $506,400 Net Rev Loss $21,000 $18,000 $62,000 $50,700 $36,300 $57,000 $72,300 $126,600 Lost Gross Revenue: $1,680,702 Lost Net Revenue: $342,900 and our project began March 25, 2016 AIM PRIMARY GOAL: Reduce MD decision to admit to ED Departure time by 33%, 200 minutes. Current: 439 min., Stretch Goal is 153 Min. National: Top Quartile min SECONDARY GOALs: Decrease LWOBS to <5% Current: 7.1% Decrease wait time for discharge-inpatients by 50% Current: min MEASURE BIB (Body in Bed): Admit decision to ED departure BOB (Body out of Bed): Patient has left the building 3

4 DISCOVERY 57%-68% of discharges (BOB) are after 1500 Services such as housekeeping, transportation will be needed to handle the flow. 10 DISCOVERY-TOOLS Gemba-observed, listened to VOC (Voice of the customer) Data-verified VOC-Batching all levels Med Rec in ED-23% 3- Fishbone-Cause Effect Diagram: 3 themes Discharge Order by 11-Med Rec, workflow, phy-wows ED Decision to admit to leaving (BIB): batching req beds, transport, housekeeping BOB-Nurse, CM, consultants, more tests, rides Stake Holder Analysis-staff nurses, physicians Value Stream Mapping Waste Analysis: Waiting, inventory & defects were highest. Look at cost of intellect Simulation exercise: C-Suite, phy (ED & Hosp), CM, Housekeeping, nursing staff DISCOVERY Mean: 184 min, Best 74 min. Charge nurse states- when given discharge orders this nurse gets it done Goal: move nurses to mean, 184 min; stretch: 120 min Star Nurses highlighted on Quality board Better 12 4

5 DISCOVERY Physician Orders Finalized 50% decrease after 2 & 4 PM 40% increase before 10 AM 13 PLAN MUST HAVE S TO DECREASE LWOBS & HOLDS 1.CM-early identification of Needs 2.Physician rounding & orders finalized by 11am 3.Staff at Core 4.Housekeeping: ED, OR, Pt units; Housekeeping change in staffing 5.Identification of OR patients-beds 6.Late Starts-OR PLAN- CONTINUED 7. Transport for ED 8. Med reconciliation started in ED, completed on unit with history & assessment 9. Docs using wows during rounding to prevent batching & early finalization 10. ED Nurse Triage: consistency in application of ESI 11. ED Goal: < 60 min, bed assigned to floor (BIB) 12.B3 Goal: < 180 min, finalized order to discharge (BOB) 5

6 DO: IMPROVEMENT/PRIORITY MATRIX days to complete 1.Create a sign to Alert EVS not to clean the patient rm-patient will be returning-decrease PCI EVS waste 2.Use sitters to transport or assign a person from the unit to decrease intellect waste 3.Pull BIB: Assign rooms as available, not batching 4.Pull BOB: Hospitalist to see pt., order discharge and final discharge as they go-not batch 5.IPOC-start discharge plan sooner-day before, then at admission-push BOB DO: IMPROVEMENT/PRIORITY MATRIX 1.ED-start Med Rec, complete if possible 2.Unit: complete Med Rec with nursing history & assessment 3.Educate staff & charge nurses to why important to BIB to BOB-use 4.Admitting hospitalist to notify at change of shift who to round on first so they could be discharged; 5.Identify late starts-or, how many beds needed: Daily huddle DO: IMPROVEMENT/PRIORITY MATRIX-60 DAYS Transporter in ED-add FTE Housekeeper in ED-OR-Add FTE Increase Housekeeping on units Scripting First Look: in progress ED log moved to Electronic vs manual ED Nurse ESI Triage: Baseline test Mean -81% 6

7 CHECK-ADOPT RESULTS 100% 75% 50% 25% Moving Leading Indicators Bed Assigned Time to Departure Time [% < 60 mins] 56% 70%-Mean 53 min 67% % Discharge Orders Finalized Before Noon 43% 85% 81% % Patient Out the Door Within 180 Mins of Final Order Mean 127 min 66% 72% 0% May-16 Jun-16 Apr-16 May-16 Jun-16 May-16 Jun-16 0% RESULTS Project Initiated Project Initiated 7

8 RESULTS Project Initiated Cost -LWOBS COST R Oct-Mar: $886,851Gross & $217,950 Net/Qtr Apr-June:$271,000 Gross & $ 67,800/Qtr Start Now July '15 Aug '15 Sept '15 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Mar '16 April '16 May'16 June '16 Gross Rev Loss $85,000 $72,000 $250,000 $202,800 $145,200 $228,000 $289,200 $506,400 $372,000 $158,400 $85,000 $27,600 Net Rev Loss $21,000 $18,000 $62,000 $50,700 $36,300 $57,000 $72,300 $126,600 $93,000 $39,600 $21,300 $6,900 Lowest Loss in a year!! From $126,600-Feb to $6,900 June 15:1 ROI $$$$$ MONTHS LATER..SUSTAINED GAINS Other outcomes: BOB Out the door- 116 min, 81% meeting the goal BIB MD decision-bed 121 min LWOBS 0.6% Holds 0-6 Decreased LOS All D/C pts (40%) Decreased LOS Fast Track pts (45%) Decreased holds in PACU/Med Day Increased customer & staff satisfaction-inpt & ED Better efficiency/utilization of staff 8

9 EXECUTIVE SUMMARY Buy-in and participation by your executive team Staff are not just involved, they run the show so they need to buy into the process A Sense of Purpose to the behaviors & tactics will drive the results compelling story Leaders who are able to give up control Pre-work so that the staff understands where to focus Monitor Results-re-direct course as needed to sustain gains WHO ARE THE WINNERS? CONTINUOUS process improvement doesn t end with a Lean Project It is the Ongoing Journey! 26 9