Hospital Flow: Right Care, in the Right Place, at the Right Time. Pat Rutherford, RN, MS Vice President, Institute for Healthcare Improvement

Transcription

1 Q11 This presenter has nothing to disclose Hospital Flow: Right Care, in the Right Place, at the Right Time Pat Rutherford, RN, MS Vice President, Institute for Healthcare Improvement IHI s National Forum December 11, 2017 Orlando, Florida Quick Course Objectives Understand and describe how to apply the conceptual framework for system optimization to improve hospital-wide patient flow Utilize an approach for sense-making regarding the multiple strategies for improving hospital operations and patient flow throughout the hospital Analyze organizational capability, change concepts and successful interventions for creating a sustainable system for system-wide hospital flow, so that patients receive the right care, in the right place, at the right time 1

2 The Problem and the Opportunity Addressing vexing issues of patient flow in hospitals is essential to ensure safe, high quality, patient-centered care. Failure to provide the right care, in the right place, at the right time puts patients at risk for sub-optimal care. Poorly managed hospital flow also adds to the already taxing burden on clinicians and staff and diverts their attention from clinical care. Improving hospital flow is critical lever for increasing value -- for patients, clinicians and health care systems. Don Berwick s Reflections on Patient Flow As in the world of patient safety, the intellectual challenges in the sciences of flow proved to be of two major types to master the complex theories and approaches that had matured in other industries and academic disciplines far from healthcare, and, at the same time, to adapt and invent new theories helpful in special contexts of healthcare systems. p.xi Will flow ever acquire the patina of charisma that fuels today s work on patient safety? I doubt it.but whether so honored or not, the problem of flow is every bit as consequential for the health of our systems and the well-being of our patients. p.xii -- Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement Kirk Jensen, Thom A. Mayer, Shari J. Welch, Carol Haraden, Leadership for Smooth Patient Flow, ACHE Management Series, Health Administration Press,

3 So-Called "Flow Failures" are Disrespectful to Patients The number one reason to improve the movement of patients through health care settings is because bad flow is disrespectful to patients and families. Our inability to more effectively design and manage processes also wears on clinicians and staff decreasing their efficiency and productivity, undermining joy in work, contributing to burnout, and decreasing job satisfaction. But our patients and families bear most of the burden. We make patients wait in the wrong places. We make them seek care in the wrong units. If you were to walk through most hospitals today, you will probably find multiple problems with patient flow. So-Called "Flow Failures" Are Disrespectful to Patients By Maureen Bisognano Thursday, August 25, 2016 System-Level Improvement Requires Will, Ideas, and Execution 3

4 Hospital Flow Change Ideas Demand System Shape the Demand (reduce bed days; reduce ED visits; smooth elective surgeries and downstream bed utilization) Match Capacity to Demand (reduce delays in moving patients to appropriate units throughout hospital; ensure patients are admitted to the appropriate unit) Redesign the System (increase throughput; reduce bed days, manage LOS outliers, and reduce delays and waiting times) Quick Course Agenda 8:30AM 8:45AM 10:00AM 10:30AM 12:00PM 1:00PM 2:30PM 2:45PM 3:45PM 4:00PM 4:30PM Introductions and Overview of Minicourse Strategies to Achieve System-Wide Hospital Flow Break Case Study: Cincinnati Children s Hospital Medical Center Lunch Case Study: KP Sacramento Break Case Study: Memorial Hermann General Q&A & Wrap-up Adjourn Optional Discussion: Managing Patients with Psychiatric and Behavioral Health Conditions in the ED 4

5 Quick Course Faculty William Browder MD FACEP Chief of Emergency Medicine Sentara Hospitals Norfolk and Best Practice Chair Sentara Leigh Hospital Katharine Luther, RN, MPM Director of Quality, UTHealth McGovern Medical School Karen Murrell, MD, MBA Assistant Physician in Chief for Process Improvement and Optimization, Chief of Emergency Medicine, Kaiser South Sacramento Pat Rutherford, RN, MS Vice President, Institute for Healthcare Improvement Frederick C. Ryckman, MD Recently retired Sr. Vice President for Medical Operations, Professor of Surgery and Transplantation, Cincinnati Children s Hospital Medical Center Achieving Hospital-wide Patient Flow: Right Care, Right Place, Right Time 5

6 On Wasting My Time The Numbers Posted by Jess Jacobs If you've wondered why I've been under the radar lately, look no further than my odyssey of medical maladies; in addition to my ongoing struggle with POTS, this year I've had: a kidney infection, shingles, pneumonia, a pulmonary embolism, and four blood transfusions. Since I m a numbers person, I downloaded my claims data from my insurer to get a better idea of how much time I ve wasted in the healthcare system since January Useful Visits This last year I had 56 outpatient doctor visits, 20 emergency room visits, and spent 54 days inpatient. But how many of these visits were useful? As you can see in the table below, not many. On average I wait 20 hours to get a bed in the hospital. My last two admissions were doozies last time I spent 48 hours in an on-call room, the time before that I spent 27 hours in a hallway (with a pulmonary embolism). I didn t sleep the entire time I was in these makeshift environments which is obviously detrimental to the healing process. I understand that my case is complicated and it takes a significant amount of time to coordinate. However, there's no reason I need to physically be in the physician's office or at the hospital while they make phone calls on my behalf. I m a social person and every second I spend in the hospital or ill is another second I m missing out on friends and family, that I'm missing out on life. So yes, I owe the medical system my life for giving me blood when my hemoglobin drops deathly low. But there's no reason a 4 hour transfusion required 84 hours of negotiation and frustration. There's no reason that only 4.75% of outpatient visits and.08% of my hospitalizations are spent actively treating my condition. There's no reason that I spent two solid months (1540 hours, 64.2 days) of this year waiting instead of healing. So, please, stop wasting my time. Stop wasting my life. 6

7 Patient Story A year ago, I went to the ED at a nearby hospital because I was experiencing severe head pain, extreme vertigo, some numbness on my left side, and was rather confused. I got there around 7PM, and I was seen in an exam room the first time around midnight. Since I suffer from migraines, they may have assumed that I had a migraine headache (regardless of that fact that I was telling them that this experience was very different than my usual episodes). My impression was that I was waiting for so long because the ED was filled with people and there were only 2 nurses in the ED. It was close to 4:30AM when I finally saw a physician, who said there s really not much we can do for you. He said it would be best to go home and rest in my own bed, since the hospital was way too crowded for me to stay. So I went home. Patient Story (continued) I woke up the next morning around 9AM, and I felt like things were getting worse. I spoke to a friend, and she told me to go back to the ED immediately to request imaging. I did, but it was a fight to get neurological tests done. Pushing and pushing, they finally agreed. I had suffered a vertebral artery dissection and a massive blood clot had formed near the tear in the artery. From that, I experienced a Transient Ischemic Attack that could have resulted in a major stroke. When the doctors saw these results, they apologized for sending me home because of the overcrowding in the ED and hospital the night earlier. I was cared for in the Neuro Unit for more than a week, and it took over six months to recover. 7

8 ED Boarding and Mortality Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities. Hospital mortality and hospital LOS are associated with length of ED boarding. Singer, A. J., Thode Jr, H. C., Viccellio, P. and Pines, J. M. (2011), The Association Between Length of Emergency Department Boarding and Mortality. Academic Emergency Medicine, 18: The Association Between Length of Emergency Department Boarding and Mortality Academic Emergency Medicine Volume 18, Issue 12, pages , 13 DEC 2011 pp

9 Association Between Intensive Care Unit Transfer Delay and Hospital Mortality: A Multicenter Investigation Observational cohort study on medical-surgical wards at 5 hospitals to investigate the impact of delayed ICU transfer. A total of 3789 patients met the critical ecart threshold before ICU transfer, and the median time to ICU transfer was 5.4 hours. Delayed transfer (>6 hours) occurred in 46% of patients (n = 1734) and was associated with increased mortality compared to patients transferred early (33.2% vs 24.5%, P < 0.001). Each 1-hour increase in delay was associated with an adjusted 3% increase in odds of mortality (P < 0.001). In patients who survived to discharge, delayed transfer was associated with longer hospital length of stay (median 13 vs 11 days, P < 0.001) Delayed ICU transfer is associated with increased hospital length of stay and mortality. Use of an evidence-based early warning score, such as ecart, could lead to timely ICU transfer and reduced preventable death. Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: A multicenter investigation. J Hosp Med Nov;11(11): Burning Platform? Cracked Foundation? Either way, change is needed It s an expression you hear all the time when people get together to talk about improving healthcare. We need a burning platform, someone inevitably says, then we could get something done. While it s true a crisis often drives reform, it s a pretty grim metaphor do we really want to achieve better care in the future by having things spin out of control now? And what are we saying to people who are struggling with the system as it is when we imply regret that in Canada we can t seem to manage anything worse than a smoulder? Discussions often centre around what some Ontario organizations are doing to promote integrated care, or how badly the system is failing to deliver it for some patients. But the more I thought about it, the more I wondered whether it s the right metaphor. We can debate whether Ontario has a burning platform in healthcare but the visual for me is different. I think what we have is a cracked foundation: somewhat hidden and getting worse. Cathy Fooks, President & CEO, The Change Foundation (Fall 2017) 9

10 What would success in achieving hospital-wide flow look like at your hospital? Recommended Performance Goals Decrease overutilization of hospital services Relocate care to more appropriate care settings outside the hospital Decrease complications and harm resulting from errors and hospital-acquired conditions Manage LOS outliers Optimize patient placement to insure the right care, in the right place, at the right time Reducing delays in treatment, surgery, transfers, discharge, etc. Decrease internal diversions (boarders and off-service patients) Decrease external diversions Increase clinician and staff satisfaction with hospital operations Demonstrate a ROI for the hospital or the health system Is your goal to have a high utilization of your hospital resources (procedures, beds and staff)? What is the right goal? When do you consider adding more bed capacity? 10

11 # of Patients Hospital Occupancy Rates in MA Source: Massachusetts Hospital Profiles, Data Through Fiscal Years , Center for Health Information and Analysis Average Occupancy Rates (at hospital or unit levels) and the Day-to-Day Realities of Managing Patient Flow Time 11

12 If I had to reduce my message for management to just a few words, I d say it all had to do with reducing variation. W. Edwards Deming System-wide View of Patient Flow of Helps to Avoid Isolated Perspectives and Flow Projects 12

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14 7/16/ /14/2008 1/12/2009 4/12/2009 7/11/ /9/2009 1/7/2010 4/7/2010 7/6/ /4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/ /28/2011 3/27/2012 6/25/2012 9/23/ /22/2012 3/22/2013 6/20/2013 9/18/ /17/2013 3/17/2014 6/15/2014 9/13/ /12/2014 3/12/2015 6/10/2015 9/8/ /7/2015 3/6/2016 6/4/2016 9/2/ /1/2016 3/1/2017 5/30/2017 8/28/2017 # of Patients with a New Failure 7/16/ /14/2008 1/12/2009 4/12/2009 7/11/ /9/2009 1/7/2010 4/7/2010 7/6/ /4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/ /28/2011 3/27/2012 6/25/2012 9/23/ /22/2012 3/22/2013 6/20/2013 9/18/ /17/2013 3/17/2014 6/15/2014 9/13/ /12/2014 3/12/2015 6/10/2015 9/8/ /7/2015 3/6/2016 6/4/2016 9/2/ /1/2016 3/1/2017 5/30/2017 8/28/2017 # of Patients with a New Failure 7/16/ /14/2008 1/12/2009 4/12/2009 7/11/ /9/2009 1/7/2010 4/7/2010 7/6/ /4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/ /28/2011 3/27/2012 6/25/2012 9/23/ /22/2012 3/22/2013 6/20/2013 9/18/ /17/2013 3/17/2014 6/15/2014 9/13/ /12/2014 3/12/2015 6/10/2015 9/8/ /7/2015 3/6/2016 6/4/2016 9/2/ /1/2016 3/1/2017 5/30/2017 8/28/2017 7/16/ /14/2008 1/12/2009 4/12/2009 7/11/ /9/2009 1/7/2010 4/7/2010 7/6/ /4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/ /28/2011 3/27/2012 6/25/2012 9/23/ /22/2012 3/22/2013 6/20/2013 9/18/ /17/2013 3/17/2014 6/15/2014 9/13/ /12/2014 3/12/2015 6/10/2015 9/8/ /7/2015 3/6/2016 6/4/2016 9/2/ /1/2016 3/1/2017 5/30/2017 8/28/2017 # of Patients with a New Failure # of Patients with a New Failure Use of Simple Rules in Complex Systems When establishing hospital-wide goals, consider adapting three simple rules for governing complex systems for achieving hospital-wide patient flow (right care, right place, right time). Right Care/Right Place: Patients are placed on the right clinical unit alongside the right clinical team with disease-specific expertise Right Time: No delay greater than two hours in patient progression (based on clinical readiness) from clinical areas and units throughout the hospital (e.g., two hours from ED to inpatient unit, one hour from PACU to surgical unit, etc.) Operational Capacity: Ensure capacity on each unit or clinical area at the beginning of each day (e.g., 1 or 2 available (and staffed) beds at 7:00 AM) The hospital flow oversight team should create a hospital-wide learning system to understand failure to achieve these simple rules and develop approaches to mitigate these failures. The challenge of complexity in health care, British Medical Journal, September Delayed or Canceled Surgery Due to Bed Capacity Daily Critical Flow Failures James M. Anderson Center for Health Systems Excellence PICU Bed Not Available for Urgent Use Patients who Utilize an ICU bed b/c an Appropriate Bed is Not 9 Available Psychiatry Patients Placed Outside of their Primary Unit 14

15 James M. Anderson Center for Health Systems Excellence System Wide Patient Flow Delays Six Ways Not to Improve Patient Flow: A Qualitative Study Narrowly focused initiatives reflected a decentralized system and the lack of a coherent system-level strategy for patient flow Well-established principles exist for improving timeliness and efficiency -- assess capacity and demand, ascertain and address the causes of variation and streamline care processes. Improving efficiencies in isolated areas will not lead to improved hospital-wide patient flow (need to focus on the greatest system constraint and scrutinize how different sub-systems throughout the hospital impact each other) Move beyond a proliferation of piecemeal initiatives to a coherent strategy of identifying the greatest constraints, and after the greatest constraint has been addressed move to the next constraint in the system. Without a system perspective to inform improvement efforts, the most promising initiatives may become just another dismal entry in The How-Not-To Guide to patient flow Kreindler SA Six ways not to improve patient flow: a qualitative study BMJ Qual Saf 2017;26:

16 Hospital Occupancy Rates Based on AHA data, overall nationwide hospital inpatient occupancy was 67.8% (AHA ); range was from 33.6% to 74%) Once managed efficiently, US hospitals, on average, could achieve an percent bed occupancy rate without adding beds at capital costs of approximately $1 million per bed. As a result of smoothing the scheduling of elective surgeries, improving discharge efficiencies, use of advanced data analytics and other interventions to improve flow at CCHMC, the hospital s quality of care improved even as the occupancy rate grew from 76 percent to 91 percent. Hospital officials also report improved overall safety for patients and reduction in stress on the doctors and nurses who treat them. Litvak E., Bisognano M. More Patients, Less Payment: Increasing Hospital Efficiency In The Aftermath Of Health Reform. Health Affairs, 2011, vol. 30, No. 1, pp s/achieving-hospital-wide-patient- Flow.aspx?utm_source=ihi&utm_campaign=Flow- WP&utm_medium=rotating-feature-2 16

17 Strategies to Achieve System-Wide Hospital Flow Outcomes Strategies Primary Drivers Make Delivering the Right Care, at the Right Time and in the Right Place a Strategic Priority Align Medical Staff and Hospital Executives to Achieve Improved Flow Decrease overutilization of hospital services Optimize patient placement to insure the right care, in the right place, at the right time Increase clinician and staff satisfaction Demonstrate a ROI for the systems moving to value-based care strategies Will Ideas Execution Adopt Value-based Care Models to Improve Patient Flow Demonstrate that Improved Flow has a Positive Return on Investment Connect the Work of Departments and Units to Hospital-Wide Flow Strategies Shaping or Reducing the Demand Matching Capacity and Demand Redesigning the System Provide Oversight of System-Level Performance by Executive Leaders Utilize of Hospital-wide Metrics to Guide Learning and Improvement to Achieve Results Create a System for Achieving Breakthrough Performance Improvement Build Quality Improvement Capability at All Levels of the Organization Strategies to Achieve System-Wide Hospital Flow Make Delivering the Right Care, at the Right Time and in the Right Place a Strategic Priority Align Medical Staff and Hospital Executives to Achieve Improved Flow Building Will Adopt Value-based Care Models to Improve Patient Flow Demonstrate that Improved Flow has a Positive Return on Investment Connect the Work of Departments and Units to Hospital-Wide Flow Strategies 17

18 Strategies to Achieve System-Wide Hospital Flow Provide Oversight of System-Level Performance Execution Utilize Hospital-wide Measures to Guide Learning and Improvement to Achieve Results Create a System for Achieving Breakthrough Performance Improvement Build Quality Improvement Capability at All Levels of the Organization Hospital Flow: Strategies for System Optimization Demand System Strategies 1. Shape the Demand (reduce bed days; reduce ED visits and admissions; smooth elective surgeries and downstream bed utilization) 2. Match Capacity to Demand (reduce delays in moving patients to appropriate units throughout hospital; ensure patients are admitted to the appropriate unit) 3. Redesign the System (increase throughput; reduce bed days, manage LOS outliers, and reduce delays and waiting times) 18

19 Outcomes Primary Drivers Secondary Drivers Specific Change Ideas Driver Diagram: Ideas to Improve Hospital Flow Decrease overutilization of hospital services Optimize patient placement to ensure the right care, in the right place, at the right time Increase clinician and staff satisfaction Demonstrate a ROI for health systems moving toward valuebased care strategies Shape or Reduce Demand Match Capacity and Demand Redesign the System S1. Provide end-of-life care (what care, and where) in accordance with patients wishes S2. Decrease demand for medical-surgical beds by preventing avoidable hospital readmissions S3. Relocate low-acuity care in EDs to primary care and community-based settings S4. Decrease ED visits and acute care hospital admissions S5. Decrease artificial variation in surgical scheduling S6. Decrease demand for hospital beds by reducing preventable harm S7. Utilize a data-driven operational management system for hospital-wide patient flow S8. Utilize real-time demand and capacity management processes S9. Improve efficiencies, length of stay, and throughput in key units and departments where clinical care is delivered S10. Improve the efficiency and coordination of hospital discharge processes S11. Reduce length of stay for patients with complex needs C1.1 Reliably identify patients end-of-life care wishes and proactively create and execute advanced illness care plans C1.2 Develop hospital-based and community-based palliative care programs C2.1 Improve transitions and post-hospital care to reduce readmissions for high-risk populations C3.1 Increase capacity in primary care practices to provide timely access to a care team C3.2 Develop partnerships with urgent care centers and retail clinics C3.3 Enroll patients in community-based mental health services C3.4 Have paramedics and EMTs triage and treat patients at home C4.1 Use enhanced care management and coordination of services for patient populations with complex medical care and social needs C4.2 Provide home-based primary care for high-risk populations C5.1 Redesign elective surgical schedules to create a predictable flow of patients to downstream ICUs and inpatient units C6.1 Decrease complications and harm, and subsequent increases in hospital lengths of stay, resulting from errors and hospital-acquired conditions C7.1 Forecast seasonal variations and changes in demand patterns to proactively plan for predicted volume C7.2 Assess the number of beds and staffing needed for each service to make plans to accommodate patient volume for each service C8.1 Use hospital-wide patient flow planning huddles and real-time demand and capacity problem solving C8.2 Use flexible staffing models for clinicians and staff to meet 37daily and hourly variations in patient volume in each unit C8.3 Use early recognition of high census and surge protocols to expedite plans for accommodating unplanned increases in patient volume C9.1 Increase OR throughput by improving efficiency C9.2 Improve efficiency in the ED to decrease length of stay (LOS) C9.3 Improve efficiency in the ICUs to decrease LOS C9.4 Improve efficiency in medical-surgical units to decrease LOS C10.1 Use proactive discharge planning focused on patients medical-readiness criteria for discharge C11.1 Use case management and care management for patient populations with complex needs C11.2 Use advance planning and cooperative agreements for transfers to rehabilitation facilities, skilled nursing facilities, nursing homes, and mental health treatment facilities Hospital-wide Flow Measures Hospital (Macro) Average Occupancy Rate (monthly, day of week) Readmissions within 1 week after discharge Number and percentage of readmissions within 30 days after discharge Patient experience (HCAHPS measures related to waits & delays) Clinician and staff satisfaction related to workload (ex. NDNQI) Number of off-service patients by service (monthly, day of week) Number of hospital-acquired conditions (ex. falls with injury, VAPs, etc.) Number of flow failures (definition TBD) Length of Star outliers Emergency Department ED diversions (# of diversions; hours per month) Number and percentage of patients who left without being seen Visits per day (time of day, day of week) Average length of stay (patients who are discharged; patients who are admitted) Door to provider time Time from decision to admit to transfer to inpatient unit (ICUs, Med/Surg Units) Time from decision for emergency surgeries to OR Number of ED boarders waiting to be admitted to a hospital bed (day of week, time of day) Percentage of ESI level 4 & 5 patients (low acuity) 19

20 Hospital-wide Flow Measures Critical Care Units Average Census (monthly, day of week) Average Length of Stay Number of LOS outliers per month Number of decedents spending 7 or more days in the ICU in the last 6 months of life Number of ICU diversions due to lack of capacity (# of off-service patients ) Hours of core nursing overtime and temporary nursing time Number or rate of hospital-acquired conditions Time from clinical readiness to transfer to medical or surgical beds Medical and Surgical Units Average Census (monthly, day of week) Average Length of Stay Number of LOS outliers per month Hours of core nursing overtime and temporary nursing time Number or rate of hospital-acquired conditions Time from clinical readiness to discharge time Number of off-service patients (by unit, by service) Hospital-wide Flow Measures Operating Rooms Number of emergency cases by day Number of scheduled cases by day Percentage of OR utilization (monthly, day of week) Number of changes from schedule for Elective Surgical Cases Actual and Scheduled Start Times for Elective Surgical Cases Hours of core nursing overtime and temporary nursing time (OR and PACU) Number of overnight PACU patients Time from clinical readiness to transfer from PACU to an inpatient unit 20

21 Shape or Reduce Demand S1 Provide end-of-life care (what care, and where) in accordance with patients wishes S2 Decrease demand for medicalsurgical beds by preventing avoidable readmissions S3 Relocate low-acuity care in EDs to primary care and community-based settings S4 Decrease ED visits and acute care hospital admissions S5 Decrease artificial variation in surgical scheduling S6 Decrease demand for hospital beds by reducing preventable harm C1.1 Reliably identify end-of-life care wishes and proactively create and execute advanced illness care plans C1.2 Develop hospital-based and community-based palliative care programs C2 Improve transitions and post-hospital care to reduce readmissions for high-risk populations C3.1 Increase capacity in primary care practices to provide timely access to a care team C3.2 Develop partnerships with Urgent Care and Retail Clinics C3.3 Enroll patients in community-based mental health services C3.4 Have paramedics & emergency medical technicians triage & treat patients at home C4.1 Use enhanced community-based coordination of services for patient populations with complex medical and social complex needs C4.2 Provide home-based primary care for high-risk populations C5 Redesign elective surgical schedules to create a predictable flow of patients to downstream ICUs and inpatient units C6 Decrease complications and harm, and subsequent increases in hospital lengths of stay, resulting from errors and hospital-acquired conditions Changing the Cultural Norm A national campaign encouraging everyone to have a conversation about their wishes for end-of-life care Collaboration to ensure health care systems are ready to receive and honor wishes for end of life care 21

22 Advanced Illness Planning: Respecting Choices 30 Day Readmissions: Primary & Secondary Heart Failure % 35.0% 30.0% 30 Day Readmissions Primary & Secondary Heart Failure UCSF Medical Center Heart Failure Program Annual Averages 2009 = 24% 2010 = 19% 2011 = 13% 2012 = 12% 25.0% 20.0% 15.0% Goal Line: 10.0% 5.0% 0.0% 44 UCSF Health 22

23 Reducing Non-Urgent Emergency ED Services Extend hours in Primary Care Use of Telemedicine in Emergency Departments Urgent Care Centers (many now part of health care systems) Retails Clinics Paramedics and Emergency Medical Services managing non-emergency calls* Community Health Workers connecting frequent ED users with communitybased services* Coordinated, Intensive Medical, Social, and Behavioral Health Services* Atrius Health ACO: Reducing ED Visits & Admissions Utilization of emergency rooms, hospitals and drugs tends to be lower than average: With Medicaid, demonstrated 39% fewer admits/1000 on hospital (medical) admissions and 37% fewer Emergency Room visits/1000 as compared with the health plan's network. With Medicare Advantage, demonstrated 12% fewer Emergency Room visits/1000 and 5% fewer SNF admits/1000 as compared with the plan's network. For a commercial PPO product, 30-day readmission rate that is half of the plan's network rate, and 25% fewer Emergency Room visits/1000. For a commercial HMO, demonstrated 8% fewer inpatient admits/1000 and 9.5% less Rx scripts/

24 Managing and Reducing Variability Natural Variability (Clinical Variability, Flow Variability, Professional Variability) o Random o Can not be eliminated (or even reduced) o Must be optimally managed Artificial Variability o Non-random o Not always predictable (driven by unknown individual priorities) o Should not be managed, must be identified and eliminated Eugene Litvak, PhD Institute for Healthcare Optimization Level-loading Electively-Scheduled Surgical Cases By applying variability methodology, queuing theory and the Flow Variability Management, hospitals can identify and eliminate many of the patient flow impediments caused by operational inefficiencies By smoothing the inherent peaks-and valleys of patient flow, and eliminating the artificial variability, that unnecessarily impair patient flow, hospitals can improve patient safety and quality while simultaneously reducing hospital waste and cost. 24

25 # of Patients elective surgical patients seeking ICU admission patients diverted or rejected from the ICU Michael L. McManus, M.D., M.P.H.; Michael C. Long, M.D.; Abbot Cooper; James Mandell, M.D.; Donald M. Berwick, MD; Marcello Pagano, Ph.D.; Eugene Litvak, Ph.D. Impact of Variability in Surgical Caseload on Access to Intensive Care Services, Anesthesiology 2003; 98: Average Occupancy Rates (at hospital or unit levels) and the Day-to-Day Realities of Managing Patient Flow Eliminate Artificial Variation >> Shapes Patient Demand Time 25

26 C.diff Infection Rates in Hospitals Many hospitals acknowledge that C. diff infections are a widespread problem, especially as the CDC estimates that 94 percent of cases occur in hospitals. C. diff infections increase patient length of stay by more than 55 percent and may increase the cost of their care by 40 percent or more. More worrying, 500,000 patients are infected annually and 29,000 patients die each year from the drugresistant superbug, so researchers are focused on finding potential treatments. Two solutions for hospitals to cut down on the infection risk: make sure staff follow hand-hygiene protocols and establish antibiotic stewardship programs Match Capacity and Demand S7 Utilize data-driven operational management system for hospital-wide patient flow S8 Utilize real-time demand and capacity management processes C7.1 Forecast seasonal variations and changes in demand patterns to proactively plan for predicted volume C7.2 Assess the number of beds and staffing needed for each service to make plans to accommodate patient volume for each service C8.1 Use hospital-wide patient flow planning huddles and real-time demand and capacity problem-solving C8.2 Use flexible staffing models for clinicians and staff to meet daily and hourly variations in patient volume in each unit C8.3 Use early recognition of high census and surge protocols to expedite plans for accommodating unplanned increases in patient volume 26

27 Use Data Analytics to Understand and Manage Seasonal and Day of the Week Variations in Demand Can you predict a surge in admissions for patients with medical conditions in the winter months? Use seasonal flex units to manage increases in medical patients during the winter months Can you anticipate which units need more bed capacity? (clue which services consistently have a large number of off-service patients) Use data analytics to quantify needs of each service Do you have a regular surge of activity mid-week with the hospital census regularly reaching >95% occupancy? Smooth elective surgical schedules (particularly for patients who will require ICU care post-op) RN Capacity for Predicted ED Demand Aggregate Demand/RN Capacity Projected Total RN Demand Total RN Staffing 27

28 Right-Sizing Hospital Units Unscheduled and scheduled patients should be provided with separate bed capacities Capacity for scheduled demand (mostly surgical) could be determined by computer simulation modeling; average utilization of beds for scheduled admissions could potentially be 90% Capacity for the unscheduled demand (medical and emergent/urgent surgical) should be determined by Queuing Theory modeling; the rule of thumb for the average utilization of beds for scheduled admission is ~ 80%. Why? Institute for Healthcare Optimization 2016 Managing Natural Variability (unscheduled patients) Waiting time 80% utilization Demand Institute for Healthcare Optimization

29 # of Patients # of Patients This explains the observed higher nursing cost per bed day in smaller wards and the lower average occupancy observed to be associated with the smaller specialty bed pools. The figure of 3% turn-away was considered to be a pragmatic compromise between operational efficiency and the capital cost issues applicable to the UK but comes at the cost of not being able to guarantee waiting time targets. turn-away - a measure of the chaos, difficulty and effort implied in running the hospital, i.e. ambulances diverted elsewhere, patients held on trolleys in the emergency department, medical patients in surgical beds, cancelled operations, managers and clinicians hastily rearranging schedules, bed management meetings and general operational complexity. 30-bed unit Jones R (2011) Hospital bed occupancy demystified. British Journal of Healthcare Management 17(6) 24 Demand/Capacity Management What nurse staffing is needed to consistently provide safe and quality care? Time Staffing for >95% census/occupancy Time Staffing for > average census/occupancy Eugene Litvak, PhD, Institute for Healthcare Optimization 29

30 Nurse Staffing, Hospital Operations, Care Quality, and Common Sense 1. Staff hospitals 24/7 according to the peaks in both bed occupancy and admissions. 2. Be "creative" by introducing dynamic PNRs that will fluctuate in a synchronous manner with census and admissions 3. Legislate PNRs 4. Preserve the status quo and do nothing. 5. Change hospital patient flow management. Litvak E, Laskowski-Jones,L; Nurse staffing, hospital operations, care quality, and common sense; Nursing, August Nurse Staffing and Hospital Mortality In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care Maintaining RN staffing levels that are consistent with each patient's requirements for nursing care underscores the importance of flexible staffing practices that consistently match staffing to need throughout each patient's stay Nurse staffing models that facilitate shift-to-shift decisions on the basis of an alignment of staffing with patients' needs and the census are an important component of the delivery of care. Risk of death among patients increased with increasing exposure to shifts with high turnover of patients. Staffing projection models rarely account for the effect on workload of admissions, discharges, and transfers Nurse Staffing and Inpatient Hospital Mortality, Needleman J., Buerhaus P., et al. N Engl J Med 2011; 364: , March 17,

31 Real-Time Demand and Capacity (RTDC) Management Processes Using Real-Time Demand Capacity Management to Improve Hospitalwide Patient Flow; Resar, R; Nolan, K; Kaczynski, M, Jenson, K; The Joint Commission Journal on Quality and Patient Safety; May 2010, Vol 37, No 5 Results at UPMC Resar,, Roger Resar, M.D.; Kevin Nolan, M.A.; Deborah Kaczynski, M.S.; Kirk Jensen, M.D., M.B.A., F.A.C.E.P., Management to Improve Hospital wide Patient Flow, Joint Commission Journal on Quality and Safety, May 2011 Volume 37 Number 5, pp r 31

32 Surge Planning Census Acuity Green Yellow Orange Red Other STATUS: Green Reflects an optimally functioning system, a state of equilibrium, homeostasis. Staff describe it as, a good day. Yellow Reflects the state of early triggers which identifies and allows the system to initiate early interventions. Orange Reflects escalating demand without readily available capacity. In this state aggressive action required to avoid system overload and ultimate gridlock. Red Reflects a state of gridlock as a result of system overload. The system should respond by using its organizational Disaster Plan. Staff Redesign the System S9 Improve efficiencies, length of stay, and throughput in key units and departments where clinical care is delivered C9.1 Increase OR throughput by improving efficiency C9.2 Improve efficiency in the ED to decrease LOS C9.3 Improve efficiency in ICUs to decrease LOS C9.4 Improve efficiency in medical-surgical units to decrease LOS. S10 Improve efficiencies and coordination of discharge processes S11 Reduce length of stay for patients with complex needs C10 Use proactive discharge planning focused on patients medical-readiness criteria for discharge C11.1 Use case management and care management for patient populations with complex needs C11.2 Use advance planning and cooperative agreements for transfers to rehabilitation facilities, skilled nursing facilities, nursing homes, and mental health treatment facilities 32

33 Separate Flows for Elective and Non-Elective Surgical Cases Mayo Clinic Florida Surgical volume and surgical minutes increased by 4% and 5%, respectively; Prime time use increased by 5%; Overtime staffing decreased by 27%; Day-to-day variability decreased by 20%; The number of elective schedule same day changes decreased by 70%; Staff turnover rate decreased by 41%. Net operating income and margin improved by 38% and 28%, respectively C. Daniel Smith, et al. Re-Engineering the Operating Room Using Variability Management to Improve Healthcare Value. Journal of the American College of Surgeons, Volume 216, Issue 4, Pages , April Bed MICU We need more beds! Emergency Center Reduced EC ICU admit time Sepsis Manage ment Bela Patel, MD and Khalid Almoosa, MD Reliable weaning protocol ICU VAP, CR-BSI bundles Standardize family meetings Reduce admission delays Stabilization Weaning Complications End-of- Life Ward Home Other facility Wards RRT team Sepsis protocol Weaning protocol VAP & BSI prevention Family meetings RRT to reduce floor codes 33

34 We have plenty of beds! VAP/ BSI rates Zero - $54,000/$ 35,000 EC- ICU 53% to 75% in 4 hrs Hospital LOS decreased 1.5 days $$ Floor codes decreased 50% End of Life ICU stay decreased 3.3 days Mortality decreased by 13%, CMI up 15%, Occupancy decreased from 94.5% to 85.5% Monthly admissions: from 89.4 to $5.1 Million saved James M. Anderson Center for Health Systems Excellence 34

35 Increasing Nurses Time in Direct Care Eliminate waste (hunting and gathering, re-work, workarounds, etc.) mandated ratios isn t the only solution Nurses spend more time in direct care (goal = 60%) show that waste has been eliminated and nurses time is reallocated to direct patient care activities that create value for patients and family members Nurse spend more time in value-added care includes important work, such as customization of care to meet needs and preferences of patients more appropriate measure than direct patient care (but more subjective) Rutherford P, Bartley A, Miller D, et al. Transforming Care at the Bedside How-to Guide: Increasing Nurses Time in Direct Patient Care. Cambridge, MA: Institute for Healthcare Improvement; Available at James M. Anderson Center for Health Systems Excellence 35

36 ED Median Total Length of Stay (min) Cambridge Health Alliance New ED Partially Open Rapid Assessment New ED Fully Open Patient Partner ED Median Door to Provider Time (min) Cambridge Health Alliance New ED Partially Open Patient Partner Rapid Rapid Assessment New ED Fully Open 72 36

37 KP Sacramento ED Flow Measure Before After Hours on Divert per year Percent LWOBS 6.6% 0.4% Door-to-Doc (minutes) LOS Treat & Release (hours) LOS Treat & Admit (hours) Murrell 2017 (c) Murrell 2015 KP Sacramento: Treatment Goals of ED Psychiatry Exclude medical etiologies for symptoms Rapid stabilization of acute crisis Avoid coercion Treat in least restrictive setting Form a therapeutic alliance Appropriate disposition and aftercare plan Not just assessment and boarding! Murrell 2017 (c) Murrell

38 System-Level Improvement Requires Will, Ideas, and Execution 38

39 Outcomes Primary Drivers Secondary Drivers Specific Change Ideas Driver Diagram: Ideas to Improve Hospital Flow Decrease overutilization of hospital services Optimize patient placement to ensure the right care, in the right place, at the right time Increase clinician and staff satisfaction Demonstrate a ROI for health systems moving toward valuebased care strategies Shape or Reduce Demand Match Capacity and Demand Redesign the System S1. Provide end-of-life care (what care, and where) in accordance with patients wishes S2. Decrease demand for medical-surgical beds by preventing avoidable hospital readmissions S3. Relocate low-acuity care in EDs to primary care and community-based settings S4. Decrease ED visits and acute care hospital admissions S5. Decrease artificial variation in surgical scheduling S6. Decrease demand for hospital beds by reducing preventable harm S7. Utilize a data-driven operational management system for hospital-wide patient flow S8. Utilize real-time demand and capacity management processes S9. Improve efficiencies, length of stay, and throughput in key units and departments where clinical care is delivered S10. Improve the efficiency and coordination of hospital discharge processes S11. Reduce length of stay for patients with complex needs C1.1 Reliably identify patients end-of-life care wishes and proactively create and execute advanced illness care plans C1.2 Develop hospital-based and community-based palliative care programs C2.1 Improve transitions and post-hospital care to reduce readmissions for high-risk populations C3.1 Increase capacity in primary care practices to provide timely access to a care team C3.2 Develop partnerships with urgent care centers and retail clinics C3.3 Enroll patients in community-based mental health services C3.4 Have paramedics and EMTs triage and treat patients at home C4.1 Use enhanced care management and coordination of services for patient populations with complex medical care and social needs C4.2 Provide home-based primary care for high-risk populations C5.1 Redesign elective surgical schedules to create a predictable flow of patients to downstream ICUs and inpatient units C6.1 Decrease complications and harm, and subsequent increases in hospital lengths of stay, resulting from errors and hospital-acquired conditions C7.1 Forecast seasonal variations and changes in demand patterns to proactively plan for predicted volume C7.2 Assess the number of beds and staffing needed for each service to make plans to accommodate patient volume for each service C8.1 Use hospital-wide patient flow planning huddles and real-time demand and capacity problem solving 77 C8.2 Use flexible staffing models for clinicians and staff to meet daily and hourly variations in patient volume in each unit C8.3 Use early recognition of high census and surge protocols to expedite plans for accommodating unplanned increases in patient volume C9.1 Increase OR throughput by improving efficiency C9.2 Improve efficiency in the ED to decrease length of stay (LOS) C9.3 Improve efficiency in the ICUs to decrease LOS C9.4 Improve efficiency in medical-surgical units to decrease LOS C10.1 Use proactive discharge planning focused on patients medical-readiness criteria for discharge C11.1 Use case management and care management for patient populations with complex needs C11.2 Use advance planning and cooperative agreements for transfers to rehabilitation facilities, skilled nursing facilities, nursing homes, and mental health treatment facilities Shape Demand Match Capacity and Demand Redesign the System Aims: Reduce bed days; reduce lowacuity ED visits; reduce day-of-week census variation Aims: Reduce delays in moving patients to appropriate units; ensure patients are admitted to the appropriate unit Aims: Reduce bed days, reduce length of stay; reduce waits and delays Hospital-Level (Macro) Provide end-of-life care in accordance with patients wishes Reduce avoidable readmissions Reduce readmissions for patients with complex needs Reduce hospital-acquired conditions Data-driven operational management system for hospital-wide patient flow Real-time capacity and demand management Early recognition of high census and surge planning Single rooms Seasonal swing units/beds Service line optimization (frail elders, SNF residents, stroke patients, etc.) Emergency Department Critical Care Units Medical-Surgical Units Provide end-of-life care in accordance with patients wishes Relocate patients with low-acuity needs to community-based care settings Provide end-of-life care in accordance with patients wishes Decrease complications and harm Provide end-of-life care in accordance with patients wishes Decrease complications and harm Reduce avoidable readmissions Create cooperative agreements with rehab facilities, SNFs, and nursing homes Operating Rooms Decrease artificial variation in surgical scheduling Improve predictions of admissions for various units Create staffing plans to meet predicted patient volume Improve real-time capacity and demand predictions Create staffing plans to meet predicted patient volume Improve real-time capacity and demand predictions Create staffing plans to meet predicted patient volume Improve predictions for transfers to various units Create staffing plans to meet predicted patient volume ED efficiency changes to decrease length of stay (for patients being discharged and patients being admitted) Separate flows in the ED Decrease length of stay (timely consults and procedures; aggressive weaning and ambulation protocols) Decrease length of stay for patients with complex medical care and social needs Discharge patients when patients meet clinical readiness criteria OR efficiency changes to improve throughput Separate flows for scheduled and emergency OR cases 39