Linking Performance to Improvement: Using a System-wide Measurement Tool. Society for Health Systems February 2005

Transcription

1 Linking Performance to Improvement: Using a System-wide Measurement Tool Society for Health Systems February 2005

2 Presenters Kathryn Munsterman, FHIMSS Gulf Coast Division Office Senior Management Engineer (713) Scott Poston, RN HCA Bayshore Medical Center Director of Patient Flow Management (713)

3 Objectives Learn a data-driven approach to process improvement Learn how module development facilitates project completion Learn how to map performance measures to job descriptions Learn pitfalls associated with process-driven approach to process improvement -2-

4 Redesign Initiative Roadmap Quick Hits Current State Assessment Future State Vision Gap Analysis Future State Design Implementation Evaluate and Improve -3-

5 ED Process Map Physician Physician Evaluation Evaluation ED Patient Intake ED Patient Intake Identify Identify & & Assign Assign ED ED Bed Bed Transport Transport of of Patient Patient to to Room Room Physician Physician Orders Orders Nurse Nurse Evaluation Evaluation Facility Charge Facility Charge Capture Capture & & Documentation Documentation Discharge of Discharge of Patients from ED Patients from ED Physician Physician Discharge Discharge Orders & Orders & Disposition Disposition Reporting of Reporting of Ancillary Studies Ancillary Studies Patient Patient Care Care -4-

6 Project Overview Alpha Site: Goals: To enhance patient satisfaction To streamline processes and patient care flow To improve inpatient capacity/throughput Scope of Service: Entire ED continuum of care Inpatient Intake/Discharge Beta Site: Goals: To enhance patient satisfaction To streamline processes and patient care flow To improve inpatient capacity/throughput Scope of Service: Entire ED continuum of care -5-

7 Project Structure Alpha Site Beta Site Executive Steering Executive Steering Committee Committee Executive Steering Executive Steering Committee Committee ED Steering ED Steering Committee Committee Inpatient Intake Inpatient Intake and Discharge and Discharge Committee Committee ED Redesign ED Redesign Team Team ED Redesign ED Redesign Team Team Inpatient Intake Inpatient Intake and Discharge and Discharge Redesign Team Redesign Team Radiology Radiology Sub-Team Sub-Team -6-

8 Committee Membership Executive Steering Committee Alpha Site ED Steering Committee Inpatient Intake/ Discharge Steering Committee CEO CNO CNO COO CFO CFO CNO ME Team ME Team CFO Make-it Happen Team Make-it Happen Team Members Members AVP ED Physician Liaison ED Physician Liaison ME Team ED Director ED Director Make-it Happen Lab Director Lab Director Team Members Imaging Director Imaging Director IT Director Admitting Director IT Director Admitting Director Case Management Director Inpatient Units Director Beta Site Executive Steering ED Redesign Team Radiology Sub-Team Committee CEO ED Director Imaging Director COO ED nurses ED nurse CNO ED techs/unit secretaries ED unit secretaries ME Team ED physicians Diagnostic Radiology tech ED Physicians ME Team Imaging Tech ED Director Lab Director ME Team Lab Director Imaging Director Imaging Director ED Redesign Team Inpatient Intake/ Discharge Redesign Team ED Director Inpatient staff nurses ED nurses Inpatient techs ED techs/unit secretaries Inpatient unit secretaries ED physicians House Supervisors ED registration clerks Bed Management Coordinator Lab staff Case Management Director Imaging staff Environmental Services Supervisor Environmental Services Supervisor IS staff IS staff MD Team ME Team -7-

9 Key Performance Indicators Alpha Site: Emergency Department Average Length of Stay for both Main ED & Fast Track % ED visits seen in Fast Track Laboratory tests turn around times Imaging exam turn around times Beta Site: Emergency Department Average Length of Stay Laboratory tests turn around times Imaging exam turn around times Inpatient Intake & Discharge Incremental time from Bed Request to Bed Assignment Incremental time from Bed Assignment to Bed Placement Environmental Services room turn over time -8-

10 Project Timeline Alpha Site Task Duration Feburary Mar Apr May June July 17-Feb 24-Feb Alpha Site Redesign Initiative 43 wks Project Pre-Planning 2 wks Project Kick-Off and Template Development 3 wks Emergency Department Team 38 wks Current State 5 wks Future State Visioning 4 wks Design 13 wks Implementation 16 wks Inpatient Intake and Discharge Team 38 wks Current State 5 wks Future State Visioning 4 wks Design 13 wks Implementation 16 wks Project Transition and Celebration 2 wks August through December Beta Site Task Duration May June July Beta Site Redesign Initiative 28 wks Current State 4 wks Future State Visioning 4 wks Design 8 wks Implementation 12 wks Project Transition and Celebration 1 wks Aug Sept October through December -9-

11 Performance Management Dashboard

12 Vision Provide One Stop Shop for Data: Retains information past Meditech 45 days Central location for indicators Provide facility and division level reports Point and click methodology Identify best practices and improvement opportunities -11-

13 Imaging Conceptual Design Laboratory Outpatients Main ED and Express Care PMD Emergency Department Inpatients Observation Patients Other Ancillary Departments as needed Bed Management/ Operating Room (Qtr ) -12-

14 Indicators By Shift By Test/ Procedure By Tech By Modality Incremental/ Specific Turn Around Times By Physician By Admitting Clerk/Registrar By Primary RN By Triage RN -13-

15 Phases Phase I Excel spreadsheets Manual data manipulation Reports ed to Department Directors Weekly Executive Steering Committee Meetings Phase II Access Database Updated weekly at facilities On demand printing Facility-level reports Phase III Web-based Updated weekly at the division On-demand printing Facility and Division level reports -14-

16 Performance Management Dashboard (Sample Report) -15-

17 Performance Management Dashboard (Sample Report) -16-

18 Performance Management Dashboard (Sample Report) -17-

19 Module Development

20 Module Matrix (Sample) People Process Technology Overview Facility IS Staff ED Charge Nurses Goals Install HIPAA compliant patient tracking system for ED PAS Supervisor Sponsor ED Nursing Director Improve communication between nursing, registration, and ancillary services Costs Staff training time N/A IT Staff development time Installation Identify who is accountable Specific checklist with timelines for steps of implementation Installation manual Quick reference guides Training Identify super-user Develop downtime procedures Identify trainers Develop training manual Implementation Ensure adequate number of monitors to allow for primary rolling trackers Follow-up Identify who is accountable for maintenance Communication of upgrades and issues with system -19-

21 Module Development ED Patient Tracker ED On-line Documentation Bed Management Tracker Environmental Services Tracker -20-

22 Module Development ED Patient Tracker To install HIPAA (Health Insurance Portability and Accountability) compliant patient tracking system for ED To improve communication between nursing, Triage, Fast Track, Nursing Stations, and ED Physician Office -21-

23 ED Private Patient Tracker Sample O = Ordered C = Completed (Green) T = Taken PL = Pending Late Completion (Yellow) CL = Completed Late (Red) -22-

24 Module Development ED On-line Documentation To provide a complete and legible patient chart to enhance the quality of documentation while improving the chart auditing process To improve patient transfer reporting to inpatient units To reduce data entry duplication for admitted patients -23-

25 Module Development Bed Management Tracker To increase bed availability To decrease instances of inpatient holding in the ED To increase patient and physician satisfaction through adequate availability of inpatient beds -24-

26 Bed Management Private Patient Tracker Sample Requesting Unit Request Date/Time Patient Name/Age/Sex Admitting Physician Diagnosis Bed Type Receiving Unit Bed Number Bed Assigned Time -25-

27 Module Development Environmental Services Tracker To allow Environmental Services staff to track dirty and available beds To increase bed availability To decrease ED holding of inpatients To decrease time patients wait for a bed -26-

28 Environmental Services Tracker Sample Available Beds Bed Status = Ready, Reserved Sex of Other Bed = M or F -27-

29 Environmental Services Tracker Sample Dirty Beds White: 0-29 minutes Green: minutes Yellow: minutes Maroon: 91 minutes 2 hrs Blue: Greater than 2 hrs Red: STAT Request Orange: Precautions Room (Isolation) NIS (Not in Service) to be used when the room needs to be closed NR (Not Ready) Automatic when a patient is discharged or transferred OUT Room needs to be serviced. R (Ready) Clean and ready for patients RES (Reserved) Allows room to be held/blocked STAT For notification of immediate need -28-

30 Results Achieved

31 Alpha Site: Results Achieved ED Incremental Turn Around Times Lab Turn Around Times Ordered to Verified Imaging Turn Around Times Ordered to Taken Patient Satisfaction Scores -30-

32 Alpha Site: Overall ED Turn Around Times 2:52 2:24 Target = 2:00 2:18 2:10 1:59 2:00 1:55 HH:mm 1:26 0:57 Target = 0:30 1:01 0:57 0:51 Target = 0:30 1:16 1:05 0:52 0:28 Target = 0:16 0:23 0:18 0:13 0:08 0:43 Target = 0:14 0:27 0:20 0:14 0:13 0:38 0:00 Arrival to Triage Triage to Room Room to MD Greet MD Greet to Disposition Order Disposition Order to Pt Leave 4th Q 03 1st Q 04 2nd Q 04 3rd Q

33 Alpha Site: Lab Turn Around Times: Ordered to Verified 2:09 1:58 1:55 1:40 1:26 Target = 0:55 1:16 Target = 1:05 1:18 Target = 0:55 1:24 HH:mm 1:12 0:57 Target = 0:40 0:57 0:50 1:03 0:58 0:59 1:09 1:06 1:00 0:56 0:51 0:43 0:44 0:43 0:28 0:14 0:00 CBC Chem Cardiac UA 4th Q 03 1st Q 04 2nd Q 04 3rd Q

34 Alpha Site: Imaging Turn Around Times: Ordered to Taken 3:21 2:52 2:24 Target = 2:00 Target = 1:30 2:32 2:34 2:15 2:01 HH:mm 1:55 1:26 Target = 1:00 Target = 1:00 1:52 1:34 0:57 1:01 0:48 0:44 1:09 0:59 0:56 0:28 0:00 Plain Films CT w/o Contrast CT w/ Contrast Ultrasound 4th Q 03 1st Q 04 2nd Q 04 3rd Q

35 Alpha Site: Patient Satisfaction Scores Target = th Q 03 1st Q 04 2nd Q 04 3rd Q

36 Beta Site: Results Achieved ED Incremental Turn Around Times Lab Turn Around Times Ordered to Verified Imaging Turn Around Times Ordered to Taken Patient Satisfaction Scores -35-

37 Beta Site: Overall ED Turn Around Times 1:40 1:26 1:12 1:33 Target = 0:15 Target = 1:05 1:16 1:13 1:10 1:08 1:081:09 HH:mm 0:57 0:43 0:28 0:14 Target = 0:10 0:27 0:23 0:18 0:18 0:14 0:14 0:53 0:49 0:47 0:40 0:40 Target = 0:15 0:44 0:41 0:37 0:38 0:32 0:28 Target = 0:15 0:32 0:30 0:220:210:21 0:20 0:00 Arrival to Triage Triage to Room Room to MD Greet MD Greet to Disposition Order Disposition Order to Pt Leave May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct

38 Beta Site: Lab Turn Around Times: Ordered to Verified 1:40 1:26 1:12 Target = 0:55 Target = 1:05 1:19 1:17 1:15 1:15 1:24 Target = 0:55 1:12 1:10 1:06 HH:mm 0:57 0:43 Target = 0:40 0:43 0:42 0:40 0:40 0:38 1:01 0:58 0:55 0:56 0:54 0:48 1:00 0:57 1:01 0:49 0:32 0:28 0:14 0:00 CBC Chem Cardiac UA May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct

39 Beta Site: Imaging Turn Around Times: Ordered to Taken 3:21 3:09 Target = 2:00 2:59 2:52 Target = 1:30 2:24 2:26 2:09 HH:mm 1:55 1:26 Target = 1:00 1:29 1:25 1:38 Target = 1:00 1:49 1:35 1:26 1:24 1:07 1:08 1:03 1:04 0:57 0:28 0:40 0:39 0:32 0:31 0:33 0:32 0:22 0:24 0:43 0:00 Plain Films CT w/o Contrast CT w/ Contrast Ultrasound May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct

40 Beta Site: Patient Satisfaction Scores Target = May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct

41 Next Steps Mapping Performance to Job Descriptions Modify Key Performance Indicators to become job specific Map Personnel to Key Performance Indicators Enhance job descriptions Link performance appraisals to revised job descriptions -40-

42 Lessons Learned Time and Perception Management Manage effectively through action plans and weekly update meetings Include key decision-makers in meetings Continually monitor progress Prioritization Identify and implement Quick Hits immediately Ensure priorities have been set by decision-makers Acceptance of Facility Similarities Include both formal and informal leaders Develop generic models for customization -41-

43 Key Points to Remember Ensure you have the ability to obtain the raw data to establish a baseline Ensure you have Administrative commitment for the initiative Develop a generic model to be customized when conducting multiple facility improvement projects Realistically set timelines Provide continuous feedback both positive and negative to the Directors -42-

44 Questions -43-

45 Linking Performance to Improvement: Using a System Wide Measurement Tool Kathryn Munsterman, FHIMSS Senior Management Engineer HCA Gulf Coast Division Scott Poston, RN Director of Patient Flow HCA Bayshore Medical Center 1

46 Executive Summary Healthcare administrators are challenged with leading their organizations through effective process improvement to increase productivity and streamline patient care processes to capture the shrinking healthcare dollar. Productivity ultimately becomes the bottom line for industry and can be measured through various means to identify organization success. HCA Gulf Coast Division defines organizational success as first quartile performance in patient satisfaction while adhering to budgetary constraints. Much like a vehicle dashboard, Gulf Coast Division has developed a metrics-based system to business and clinical practices toward achieving organizational goals. Over the last decade, Emergency Departments have increasingly become a patient s first point of contact with a facility. In essence, Emergency Departments are the front door to a hospital. Recognizing this fact, HCA Gulf Coast Division has targeted their Emergency Departments as a focus for process improvement initiatives; however, Emergency Departments are not isolated or stand alone departments. Other areas impact every Emergency Department s performance in a facility, such as Imaging Services, Laboratory, and Inpatient Units. This was accomplished through creating a Performance Management Dashboard (PMD), developing modules to roll out the designs initiatives to other facilities, and providing a feedback loop on improvement. The goal of the project was to develop a methodology at one facility that could be replicated to every facility within the Gulf Coast Division. The budgetary constraints are no capital renovation of the Emergency Departments and maintaining current staffing levels. We started with the Alpha site, which lasted approximately one year. As we moved to the Beta site, this project lasted approximately five months. Through the various tools created, we anticipate facilitating multiple facilities at a time with a timeline of approximately three to four months. 2

47 Redesign Initiative Overview ALPHA SITE: In an effort to improve Emergency Department processes in the Gulf Coast Division, one facility was selected as an Alpha site for the development of a multidisciplinary redesign initiative. The goals of this team were: To enhance patient satisfaction To streamline processes and patient care flow To improve inpatient capacity/throughput. The scope of the initiative included the entire ED continuum of care from patient arrival to patient disposition either home or admitted into the facility. Inpatient intake and discharge of patients was also evaluated. The Inpatient Intake and Discharge Redesign Team focused on the patient processes from patient admission order to patient room placement and patient s discharge order written to clean room available for another patient. Their goal was to streamline the bed management process. This team did not focus on the care management portion of the inpatients stay since Case Management was addressing it. Through the development of process maps for current and future states, a gap analysis was completed and key performance indicators were identified. This initiative was lead by the Division ME Team, comprised of three management engineers, financial analyst, facility intern, and external physician consultant. Facility administration identified a make-it happen employee for each design team who had the primary task of facilitating process changes on the facility side with the support of the ME Team. The project structure is shown below. 3

48 The Steering Committee Membership included: Executive Steering Committee ED Steering Committee CEO CNO CNO COO CFO CFO CNO ME Team ME Team Inpatient Intake/ Discharge Steering Committee CFO Make-it Happen Team Members Make-it Happen Team Members AVP ED Physician Liaison ED Physician Liaison ME Team ED Director ED Director Make-it Happen Lab Director Lab Director Team Members Imaging Director IT Director Admitting Director Imaging Director IT Director Admitting Director Case Management Director Inpatient Units Director The Redesign Team Membership included: ED Redesign Team Inpatient Intake/ Discharge Redesign Team ED Director Inpatient staff nurses ED nurses Inpatient techs ED techs/unit secretaries Inpatient unit secretaries ED physicians House Supervisors ED registration clerks Bed Management Coordinator Lab staff Case Management Director Imaging staff Environmental Services Supervisor Environmental Services Supervisor IS staff IS staff MD Team ME Team 4

49 The redesign teams met weekly for six hours at a time. The ED and Inpatient Intake/Discharge Steering Committees met monthly for one hour. The Executive Steering Committee met weekly for one hour. The project timeline is shown below: The ED Redesign Team focused on the patient processes throughout the ED experience from patient arrival to when the patient physically leaves the ED. (See Sample below) Physician Physician Evaluation Evaluation ED ED Patient Patient Intake Intake Identify & Assign Identify & Assign ED Bed ED Bed Transport of Transport of Patient to Room Patient to Room Physician Physician Orders Orders Nurse Nurse Evaluation Evaluation. Facility Facility Charge Charge Capture Capture & & Documentation Documentation Discharge Discharge of of Patients from ED Patients from ED Physician Physician Discharge Discharge Orders & Orders & Disposition Disposition Reporting Reporting of of Ancillary Studies Ancillary Studies Patient Patient Care Care This ED Redesign Team separated the process into the Main ED and Fast Track. After pulling data for ED turn around times and utilization of the Fast Track service, ED Redesign team identified an opportunity in optimizing the Fast Track service in an effort to reduce patient s average length of stay. With the focus on reducing the ED average length of stay, the team reviewed data from Lab and Imaging on their turn around times for ED patients. The application of time stamps for processes helped to create a metrics- 5

50 based system to monitor progress within the organization and guide performance improvement initiatives. These time stamps were: Patient Arrival Date/Time Patient Triage Date/Time Patient s Room Placement Date/Time Physician s Initial Contact (MD Greet) Date/Time Physician Discharge Order Date/Time Patient Departure Date/Time Initially, it took five months to obtain the data for development of the baseline performance for turn around times for the Lab and Imaging and the ED average length of stay. Once the baseline was identified, the Executive Steering Committee identified the standardized targets for key performance indicators. The ED Key Performance Indicators were: ED average length of stay for both the Main ED and Fast Track % ED visits seen in Fast Track Laboratory test turn around times for ED patients Imaging test turn around times for ED patients The Inpatient Intake and Discharge Key Performance Indicators were: Incremental time from bed request to bed assignment Incremental time from bed assignment to patient s bed placement EVS room turn over time Using the baseline data and Key Performance Indicators, the Redesign Teams identified gaps between current state and future state. The gaps were ranked based on ease of implementation and associated estimated costs. Action plans were developed for the prioritized gaps. (See sample action plan below) 6

51 ALPHA SITE Sample Action Plan with Timeline Issue: Need to more proactively manage patient registration process in ED. Need to move registration to bed-side or complete registration prior to patient s bed assignment Recommendation: Implement Financial Counselor position on second shift in ED. Next Steps: 1. Identify potential Financial Counselors for all shifts 2. Check with Patient Accounting Services (PAS) for approval a. PAS is conducting a volume analysis to evaluate the need for more staff 3. Educate Financial Counselors on new responsibilities a. Review all admissions, b. Redirection of Registrars workload, c. Reporting to Charge Nurse for overall registration functions, d. Report all potential transfers to Case Manager as soon as they are identified 4. Implement Financial Counselor 5. Monitor performance Responsibilities PAS TIMING June 2003 June 2003 July 2003 July 2003 Ongoing Expected Benefit: Increased accuracy of inpatient admission information; Increased patient satisfaction; Reduce patients waiting time for registration Status Approved Declined Pending Resolution Date: July

52 BETA SITE: Once the Alpha site was completed, the ME Team identified a need to streamline the process improvement initiatives. A second facility was identified as needing assistance. The scope of this initiative started addressing ED processes only, but due to the impact of other departments on the ED performance, the scope spread to include the Lab and Imaging Departments. In an effort to streamline the process, the project structure was modified to include only the key players. The revised project structure included the Executive Steering Committee, Emergency Department Redesign Team, and Radiology Sub-Team. The Committee and Redesign Team Membership included: Executive Steering ED Redesign Team Radiology Sub-Team Committee CEO ED Director Imaging Director COO ED nurses ED nurse CNO ED techs/unit secretaries ED unit secretaries ME Team ED physicians Diagnostic Radiology tech ED Physicians ME Team Imaging Tech ED Director Lab Director ME Team Lab Director Imaging Director Imaging Director The project timeline is shown below: Beta Site - Project Timeline Task Duration May June July Beta Site Redesign Initiative 28 wks Current State 4 wks Future State Visioning 4 wks Design 8 wks Implementation 12 wks Project Transition and Celebration 1 wks Aug Sept October through December The ME Team continued to use the same measures from the Alpha Site for the Beta Site. This ED Redesign Team also focused on the patient processes throughout the ED experience from patient arrival to when the patient physically leaves the ED. With the focus on reducing the ED average length of stay, the team reviewed data from Lab and Imaging on their turn around times for ED patients. The same time stamps for processes were utilized to help to create a metrics-based system to monitor progress within the organization and guide performance improvement initiatives. Due to prior data retrieval from the Alpha site, baseline data was readily available. Also, the key performance indicators and targets had been established for the Alpha site. 8

53 Performance Management Dashboard In developing the methodology to be replicated at other facilities, the first hurdle the ME Team had to overcome was obtaining the raw data. With competing demands for Information System personnel time, data retrieval was delaying the initiative from moving forward. The ME Team identified the need for a dedicated Information Systems employee to the project. Once this employee joined the ME Team, raw data was available for manipulation into information. Once the ME Team was able to pull data out of Meditech, HCA s main clinical operating system, the ME team developed the Performance Management Dashboard. The goal of the Performance Management Dashboard was to retain data passed 45 days, to centralize performance indicators, and to provide a point and click methodology. Phase I of the Performance Management Dashboard (PMD) basically consisted of several Excel spreadsheets. This data manipulation process took appropriately two days to complete. These reports were ed to the Departmental Directors and presented in the weekly Executive Steering Committee meetings. Phase II of the Performance Management Dashboard (PMD) consisted of an Access database. With the development of this database, reporting was available to the Departmental Directors and the Administrative team on demand along with a weekly update. Requested report modification was easier to accomplish. This database was pushed out to all division facilities to aid in performance improvement initiatives. Since each facility s information was residing on individual databases, division rollup reports were not available. The ME Team was dependent on each facility s super-user appropriately maintaining their facility s Performance Management Dashboard (PMD). Phase III is a web-based Performance Management Dashboard (PMD). With a web-based tool, data maintenance has moved from the facilities to the Division level. Each facility has access to their reports as well as having the ability to view other facility s reports for comparative purposes. Division roll-up reports are also available. As the ME Team moves forward in the improvement initiative, more reports will be developed to further assist in monitoring ED, Lab, and Imaging performance. The whole process of moving from Excel spreadsheets (Phase I) to a web-based tool (Phase III) took less than 1 year. (See following sample reports) 9

54 10

55 PMD Module Development With a division goal of duplicating this process for the remaining twelve facilities within the next twelve months, the ME Team conducted site visits to the remaining facilities to aid in identifying issues in their Emergency Department. After these visits, it was apparent each Emergency Department basically suffered from the same ailments overall. Therefore, the ME Team identified the similar issues and developed a cookie cutter or module approach to these mostly technology enhancement issues. The modules developed were: PMD Module ED Patient Tracker ED On-line Documentation Bed Management Tracker Environmental Services Tracker PMD Module Matrix: In each module developed, a matrix was completed in which certain items were identified as needing to be addressed. These were overview, costs, installation, training, implementation, and follow-up. Each of these was then divided into people issues, process changes, and technology enhancements. By completing the matrix, any outstanding items to be addressed were identified. (See sample below) Overview Presentation Installation Identify who is accountable People Process Technology Comments Identify User Groups Identify benefits of Identify cost to Identify who is system implement accountable Identify potential including required Identify sponsor in changes within equipment and IT organization organization: support Develop restructuring or communication plan people (addition or to provide elimination) information on Identify goals and system, issues targets Training Identify who is accountable Identify super users Identify trainers Create work plan to implement change Identify training schedule Detailed training manual Create quick reference guides on process piece Implementation Who is accountable Monitor and report work plan/schedule progress Follow-up Who is accountable Ensure help/issue database is integrated and end users have access Create installation manual Quick reference guides include trouble shooting and use of system Monitor and report work plan/schedule progress Communication of upgrades and issues with system 11

56 ED Patient Tracker: This electronic Emergency Department Patient Tracker was developed to install HIPAA (Health Insurance Portability and Accountability) compliant patient tracking system for Emergency Department and to improve communication between nursing, registration, and ancillary services. The ED Patient Tracker was displayed on monitors in Triage, Fast Track area, Nursing Stations and the physician office. By using this tracker, the Triage nurse is able to identify open rooms to facilitate patient placement in the Emergency Department. (See sample screen shot below) ED Patient Tracker Columns: Bed/Room number Physician Name Registration Status Arrival Date Arrival Time Patient Name Patient Age Chief Compliant Tests Ordered for Lab, Micro, CT, Ultrasound o O = Test(s) Ordered o C = Test(s) Completed (Green) o PL = Test(s) Pending Late (Yellow) o CL = Test(s) Completed Late (Red) Triage Time 12

57 ED On-line Documentation: The goals for ED On-line Documentation were to provide a complete and legible patient chart to enhance the quality of documentation while improving the chart auditing process. Through identification of time stamps for specific key process steps, reports were made available allowing for real time data collection and staff performance feedback. These time stamps were: Patient Arrival Date/Time Patient Triage Date/Time Patient s Room Placement Date/Time Physician s Initial Contact (MD Greet) Date/Time Physician Discharge Order Date/Time Patient Departure Date/Time Additional benefits were identified through improved patient transfer reporting to inpatient units and a reduction in duplication of data entry for admitted patients based on connectivity to the on-line documentation module in use by inpatient units. On-line documentation allowed facilities to ensure that all necessary questions were answered by making the question required. It also prompted the nurse on questions or interventions that may be needed for that patient care. Bed Management Tracker: Bed Management is defined as a coordination of inpatient beds to maximize available resources to meet organizational demands for the provision of care while maintaining nationally recognized standards of care based on patient acuity. This was identified as another key area of focus. Bed Management remains a problem with many facilities and an ever increasing concern with the impending Joint Commission standard requiring acute care organizations to take steps to minimize, if not eliminate, the potential adverse effects associated with ED overcrowding typically associate with ED holding. The goal of the Bed Management Tracker was to increase bed availability, to decrease the instances of inpatient holding in the Emergency Department, and increase patient and physician satisfaction through adequate availability of inpatient beds for the provision of care upon request. Through the utilization of a tablet pc, the personnel responsible for bed management are able to walk the units, interacting with staff to expedite transfers and discharges and eliminate downtimes for available beds often referred to as hidden patient rooms. The Bed Management Tracker was developed in conjunction with the online documentation and nursing unit patient tracking systems to allow for immediate notification to the Bed Management staff when patients have been discharged. Bed Management is no longer dependent on phone calls to and from the nursing units to identify vacant rooms. (See sample screen shot) 13

58 Bed Management Private Patient Tracker Columns: Location requesting a bed Individual requesting a bed Request date Request time Patient name Patient age Patient sex Admitting physician Diagnosis Type of bed needed If the patient needs isolation Receiving unit Bed number Time the bed was assigned Environmental Services Tracker: Tied very closely to the Bed Management Tracker was the Environmental Services Tracker. This tracker allowed Environmental Services staff to track dirty and available beds. The goal was to increase bed availability, to decrease the instances of holding in the Emergency Department, and to decrease the length of time patients wait for a bed. The system provided notification of recently vacated beds to the Environmental Services staff and a time tracker with alerts to notify Environmental Services supervisors when beds have remained dirty for extended periods of time as 14

59 well as a means of notification from Bed Management staff when specific beds were deemed a priority based on patient demands. In this tracker, the beds were displayed two ways: Available Beds Unavailable/Dirty Beds The Bed Management Coordinator focused on available beds and the Environmental Services Supervisor focused on unavailable/dirty beds. (See sample screen shots below) Available Bed Tracker Columns: Room/Bed Status - o Bed status o Sex of the other bed (F) or (M) 15

60 Unavailable Bed Tracker Columns: Room/Bed Status - o Bed status NIS (Not in Service) to be used when the room needs to be closed NR (Not Ready) Automatic when a patient is discharged or transferred OUT Room needs to be serviced. R (Ready) Clean and ready for patients RES (Reserved) Allows room to be held/blocked STAT For notification of immediate need. o Color code White: 0-29 minutes Green: minutes Yellow: Greater than minutes Maroon: Greater than 1.5 hrs 2 hrs Blue: Greater than 24 hrs Red: STAT Request Orange: Precautions Room (Isolation) Comment field 16

61 Results ALPHA SITE Main ED: The overall turn around time goal for this facility was 3.5 hours for patients departing home. One hurdle the ED Redesign Team had to overcome was modification of physician behavior. Since the physicians are a contract service, the facility s Administration Team did not have direct authority over the physicians. The ME Team recognized this was a challenge and included the physicians in the ED Redesign Team. This increased the physician buy-in of the process improvements. Also, once information was available for individual physician performance, this information was posted in the physician/staff lounge for all to see. The basic competitive nature of physicians drove the incremental time from patient s placement in a room to the initial physician contact. Use of the ED Patient Tracker facilitated the improved incremental turn around time from arrival to triage and from triage to patient s placement in a room. This was accomplished by enabling the Triage Nurse to know when a room was available for a new patient. Once a patient arrived in the ED, an ED Tech entered the patient into the ED Patient Tracker. The Triage Nurse and Charge Nurse monitored the tracker to facilitate effective patient flow through the ED. ED Incremental Turn Around Times (Home) Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 Overall 3:30 5:25 4:50 4:09 3:42 Time from Arrival to Triage 0:16 0:23 0:18 0:13 0:08 Time from Triage to Room 0:30 1:01 0:57 0:51 0:43 Time from Room to MD Greet 0:14 0:27 0:20 0:14 0:13 Time from MD Greet to Disposition Order 2:00 2:18 2:10 1:59 2:00 Time from Disposition Order to Pt Leave 0:30 1:16 1:05 0:52 0:38 Fast Track: This facility s Fast Track was open daily from 11 am to 11 pm. This Fast Track is located outside of the ED. The targeted ED visits percentage was 20% over a 24 hour period or 25% during the hours of operation. By changing the Fast Track criteria for service from inclusionary to exclusionary, it enabled the Triage Nurses to triage more patients into Fast Track. The revised criteria excluded: Abuse Abdominal pain Chest pain Burns Pediatric patients less than 3 months old or with a fever greater than 102 Head injuries Trauma The Fast Track staffing consisted of one nurse, one physician assistant, one ED tech, and one ED registrar. By dedicating specific staff to Fast Track, this enabled the staff to form a cohesive team. 17

62 ED Fast Track Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 ALOS 1:00 2:09 1:54 1:20 1:18 % of ED Visits 20.0% 17.0% 17.0% 21.5% 23.1% % of ED Visits (11 A - 11 P) 25.0% 25.9% 27.3% 32.5% 35.0% Laboratory: The four most commonly used tests in the ED were measured. These were: Cardiac CBC Chemistry Urinalysis There are two components of this turn around time: Time the specimen was ordered to the time the Lab received the specimen and Time the Lab received the specimen to the time the Lab verified the tests. Since the internal Lab turn around time was machine-based, the time most impacted was the time from ED ordering the test to the Lab receiving the specimen. In the results below, the turn around times reported were from specimen order time to verified tests. At this facility, the Lab was located across a hallway from the ED. Pneumatic tubes were available for ED s use; however, most nurses chose to walk the specimens to the Lab. Since most ED nurses focus was on stabilizing or treating a patient immediately, this created a significant delay in Lab specimen receipt. The ED nurses tended to wait until they had time to walk the specimens to the Lab. Once the ED nurses realized this was delaying the care of their patients, the nurses were more aware of the need to take the specimens to the Lab timely. Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 CBC 0:40 0:57 0:50 0:44 0:43 Lab: Ordered to Chem 0:55 1:16 1:03 0:58 0:59 Verified Cardiac 1:05 1:58 1:18 1:09 1:06 UA 0:55 1:24 1:00 0:56 0:51 Imaging: The four most commonly ordered tests in the ED were measured. CT CT with Contrast Radiology (Diagnostic) Ultrasound There are three components of these test turn around times: Time the exam was ordered to the time completed by the Technologist Time exam completed by Technologist to time Radiologist dictates the report Time Radiologist dictates report to transcription completed In the results below, the turn around times were from the ordered time-to-time completed by the Technologist. In working with the Radiologists, the ED Redesign Team identified the dictated time for the exam was artificially inflated. In our ED s, the ED physician reads the diagnostic films themselves and the Radiologists over-reads these films; therefore, the 18

63 dictated time in the system was the over-read time. Also since our Radiologists subcontract reading of imaging studies (i.e. CT and Ultrasound) with a tele-radiology group for night and weekend coverage, the dictated time for the imaging studies may not be accurate on the evening and night shifts. ED Radiology: TAT Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 Plain Films 1:00 N/A 1:01 0:48 0:44 CT w/o Contrast 1:00 N/A 1:09 0:59 0:56 CT w/contrast 2:00 N/A 2:32 2:15 1:52 Ultrasound 1:30 N/A 2:34 2:01 1:34 ED Patient Satisfaction Scores: Since patient satisfaction is driven almost entirely on perception, it is the hardest indicator to move. Over a year time frame, the patient satisfaction score has increased from 3.03 to 3.17 on a 4.0 scale. Satisfaction Scores Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 ED Cummulative Score ED Survey Percent Complete 100% 100% 100% 100% Inpatient Bed Placement Turn Around Time: In January 2004, the Alpha site moved from a manual bed tracking system (i.e. paper log) to an electronic bed tracking system. This enabled the Alpha site CNO to track bed placement turn around times. ED Inpatient Bed Placement Target 4th Q 03 1st Q 04 2nd Q 04 3rd Q 04 ED Hold Hours 0 N/A N/A 4,568 3,466 Number of Bed Requests 33/day N/A 19/day 21/day 33/day Time from Bed Request to Bed Assigned 0:45 N/A 0:52 0:23 0:35 Time from Bed Assigned to Patient Placement in Bed 0:45 N/A 1:43 1:36 1:32 19

64 BETA SITE Main ED: The overall turn around time goal for this facility was 2 hours from patient arrival to patient departing home. As shown below, the greatest areas for improvement were the time triage is completed to patient s placement in a room and from patient placement in a room to the physician s first contact with the patient. The redesign team just finished the design and implementation started at the end of October Results are forthcoming but initial outcomes are positive. ED Incremental Turnaround Times (Home) Target TAT May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Overall 2:00 3:08 3:21 3:07 2:59 3:11 3:13 Time from Arrival to Triage 0:10 0:23 0:18 0:18 0:14 0:14 0:27 Time from Triage to Room 0:15 0:53 1:33 0:40 0:47 0:49 0:40 Time from Room to MD Greet 0:15 0:41 0:44 0:37 0:28 0:38 0:32 Time from MD Greet to Disposition Order 1:05 1:08 1:16 1:10 1:08 1:09 1:13 Time from Disposition Order to Pt Leave 0:15 0:30 0:32 0:22 0:21 0:21 0:20 Laboratory: The ME Team continued to use the same measures from the Alpha Site moving forward to the Beta Site. In the Beta Site, the Lab was located next to the ED with a pass-through window for specimens. Once the ED nurses were made aware this was being monitored, performance improved. Lab: Ordered to Verified May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Target TAT Hr:Mm Hr:Mm Hr:Mm Hr:Mm Hr:Mm Hr:Mm CBC 0:40 0:40 0:43 0:40 0:38 0:42 0:32 Chem 0:55 0:55 0:58 0:56 1:01 0:54 0:48 Cardiac 1:05 1:15 1:19 1:15 1:17 1:24 1:00 UA 0:40 0:57 1:12 1:01 1:06 1:10 0:49 Imaging: The ME Team continued to use the same measures from the Alpha Site moving forward to the Beta Site. In our ED s, the ED physician reads the diagnostic films themselves. Since the Imaging Department was not meeting its turn around time targets, a sub-team was formed which included both Imaging Department employees and ED employees. The biggest area for improvement was to develop an ordering cheat sheet. This reduced the amount of time the Technologist spent modifying exams being ordered. The next item the sub-team worked on was educating the Technologists to enter the correct time the exams were completed. Technologists waited until the end of the shift to take their exams to taken and entered the current time for the taken time. This was artificially inflating their turn around times. As with the ED Physicians once the turn around times were displayed in the department in June 2004, the turn around times improved tremendously. 20

65 ED Radiology: TAT May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 TAT TAT TAT TAT TAT TAT Target TAT Plain Films 1:00 1:25 1:29 0:32 0:40 0:31 0:39 CT w/o Contrast 1:00 1:38 1:49 0:33 0:32 0:22 0:24 CT w/ Contrast 2:00 3:09 2:59 1:07 1:26 1:03 1:08 Ultrasound 1:30 2:09 2:26 0:43 1:24 1:35 1:04 Patient Satisfaction Scores: Since patient satisfaction is driven almost entirely on perception, it is the hardest indicator to move. Over a six-month time frame, the patient satisfaction score has increased from 3.17 to 3.27 on a 4.0 scale. Satisfaction Scores Target May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 ED Cummulative Score ED Survey Percent Complete 50% 100% 34% 69% 100% 16% ED Weekly Score

66 Linking Performance to Job Descriptions Effective job analysis and job design can improve the healthcare administrators ability to meet the challenges associated with the changing healthcare market. Through utilization of the human resources professional, the process for analysis and redesign of individual job descriptions and assigned tasks can be effectively mapped to the desired outcomes and organizational goals. Once aligned with organizational goals, the finished job design should allow for greater accountability for those employees seeking ownership within the organization, and therefore yield greater productivity. Trying to guide performance improvement based on an overall turn around time creates a significant challenge, where as the ability to focus on incremental steps within the overall process guides improvements toward areas that make the biggest impact. Realizing that each individual nurse retains the ability to either positively or negatively impact the departmental performance, metrics data was provided by specific employees. The ability to capture and reproduce data to this level of detail then gives the organizational leader an opportunity to quantify markers within the annual performance review for merit increases as well giving them the opportunity for timely feedback, both positive and negative. As we move forward in the redesign initiative, the ME team is currently working with the Facility Administrators and Human Resource Departments to link individual performance with modified job descriptions. As shown earlier in this paper, the key performance indicators for each department has been identified and is being tracked. As the ME team moves forward, the anticipated next steps will be: To modify departmental key performance indicators to become job specific To map departmental personnel to key performance indicators To enhance job descriptions with specific and measurable performance indicators To link individual performance appraisals to the revised job descriptions. 22

67 Lessons Learned As with any process improvement project, there is potential for roadblocks and pitfalls. Retrospectively several areas were identified as lessons learned for the future facilities upon replication of the process improvement. Lesson 1: Time and Perception Management When discussing time management, it is important to understand that effective management is more than merely meeting deadlines, but managing perceptions as well. The time commitment required for the development of the project was clearly considerably greater than the time required for replication. However, both development and replication are effectively managed through action plans and weekly meetings for status updates with specific timelines for completion. These meetings need to include the facility s key decision-makers and the owners of the project. If the decision-makers are not included in the weekly update meetings, approval for action items is delayed and redesign team creativity is stifled if recommendations are not met with acceptance or minimal variations. Also related to time, it is important to ensure that the timeline for completion and results are realistic and the perceptions of those impacted are managed to such. Before the initiative starts, the facility decision-makers and identified project owners should identify the project scope, any project limitations (i.e. major renovations), how communication from the self-managed teams to the decision-makers should occur, desired measurable results, and the expected project timeline. For a system wide project, the redesign program must include continuous monitoring to identify the true culture shift that is required in change management to ensure long lasting results. Lesson 2: Prioritization Failures in prioritization of initiative can be a second pitfall during process implementation. Identification of high impact, low effort items that can be classified as quick hits can produce momentum for advancement of the entire project. These quick hits should be implemented as soon as possible. These successes send a message to the teams and the facility as a whole that the key decision-makers of the facility are committed to achieving the desired change. Priority setting must be clear and supported by organizational leadership to minimize conflict and ensure success. Lesson 3: Acceptance of Similarities Acceptance that each facility has similar issues from subsequent facilities has proven to be another significant challenge to the process. There are a thousand and one excuses as to why the redesign initiative will not work in another facility, but if the processes are based on true metrics driven data it becomes more difficult to refute. It is highly recommended for future projects with potential for dissemination to include both formal and informal leaders from future sites at least on an ad-hoc basis to the redesign teams to improve acceptance. An alternative would be to develop generic models for improved customization of projects upon transfer to additional facilities, with modules or templates of the most common improvements in development first. 23

68 Summary Overall this process has taken approximately two years to reach this level; however, with the performance metrics available, improvement is expected to continue. By subscribing to the Hawthorne theory, processes or performances that are consistently monitored with timely feedback will improve. Successes have been in increasing patient satisfaction scores, decreasing turn around times, and increasing usage of Fast Track, etc. Key Points to Remember: Ensure you have the ability to obtain the raw data to establish a baseline Ensure you have Administrative commitment for the redesign initiative Develop a generic model to be customized when conducting multiple facility improvement projects Set realistic timelines Provide continuous feedback both positive and negative to the Directors and Administration 24