8/28/2011 RE-INVENTING THE ACUITY ADAPTABLE ROOM/UNIT AGENDA WHY GEISINGER? 1. Design 2. Operational Model 3. Actual Data 4.

Transcription

1 RE-INVENTING THE ACUITY ADAPTABLE ROOM/UNIT This is How We Made it Work September 20, 2011 AGENDA 1. Design 2. Operational Model 3. Actual Data 4. Lessons Learned 1 2 GEISINGER HEALTH SYSTEM WHY GEISINGER? We have to ask why places like the Geisinger Health system in rural Pennsylvania...can offer high-quality care at costs well below average, but other places in America can't. We need to identify the best practices across the country, learn from the success, and replicate that success elsewhere. - President Barack Obama Fully Integrated Multi-hospital Health System Founded In 1915 Health Insurance 2.6 Million People in Rural Pennsylvania 37 practice Site; 42 Counties 1,000+ Beds System One of the 1 st Adopters of EMR Academic Training Ground 3 4 1

2 TEAM EXECUTIVE COMMITTEE DESIGN 1. Team 2. High Level Topics 3. Plans Executive Leadership Mr. Louis Shapiro Executive VP - GHS Dr. Joseph Bisordi CMO - GMC Ms. Sue Hallick CNO - GMC Ms. E. Lynn Miller CAO - GMC Mr. Tom Sokola CFO - GMC Ms. Katrina Buchholtz Administrative - GHS Kate Fleetwood Project Manager - GMC Department Chief / VP Radiology - Dr. Dominick Conca/ Mr. Michael Leighow Cardiology - Dr. Francis Menapace / Mr. Jeffrey Tiesi Surgery - Dr. William Strodel, III / Mr. Tom Weir Medicine Dr. Dennis Torretti Cardiology Dr. Randle Storm Dr. Albert Casale Nursing Ms. Denise Beechay Facilities Management Mr. Robert Davies Mr. Thomas Gensemer Mr. Alan Neuner EwingCole Mr. John Gerbner Mr. Patrick Brunner Ms. Natalie Miovski 5 6 TEAM EXECUTIVE COMMITTEE Executive Leadership Mr. Louis Shapiro Executive VP - GHS Dr. Joseph Bisordi CMO - GMC Ms. Sue Hallick CNO - GMC Ms. E. Lynn Miller CAO - GMC Mr. Tom Sokola CFO - GMC Ms. Katrina Buchholtz Administrative - GHS Kate Fleetwood Project Manager - GMC Department Chief / VP Radiology - Dr. Dominick Conca/ Mr. Michael Leighow Cardiology - Dr. Francis Menapace / Mr. Jeffrey Tiesi Surgery - Dr. William Strodel, III / Mr. Tom Weir Medicine Dr. Dennis Torretti Cardiology Dr. Randle Storm Dr. Albert Casale Nursing Ms. Denise Beechay Facilities Management Mr. Robert Davies Mr. Thomas Gensemer Mr. Alan Neuner TEAM SERVICE LINE & PRACTICE GROUPS Radiology Surgery Nursing Units / Beds Cardiology Clinics Technology Food Service Material Handling Construction / Cost Architecture Plant Operations EwingCole Mr. John Gerbner Mr. Patrick Brunner Ms. Natalie Miovski 7 8 2

3 PROJECT VISION MANDATE PROJECT VISION METRICS Opportunity to aggregate resources within Danville Hub around specific patient needs Leverages interdisciplinary strengths to increase quality Achieves a patient centered environment for specific diseases or conditions Creates value for patients Improve Patient Outcomes Lower Average Length of Stay (ALOS) Increase Complexity of Case and Increase Care to Severely Ill Decrease Mortality Rate Reduce Adverse Events (Medical Errors) Reduce Falls Reduce Intubation Times and Incidences of VAP Reduce Inefficient Staffing Costs Increase Patient & Staff Satisfaction 9 10 MASTER PLAN STRATEGIES MINI-MASTER PLANNING EXERCISE 1 Hospital Initiative Aggregate Patients by Disease/Service Line Architectural Response Hospital Within a Hospital: The Hospital for Advanced Medicine, The Heart Institute 11 HOSPITAL WITHIN A HOSPITAL CONCEPT 12 3

4 MINI-MASTER PLANNING EXERCISE NEW MAIN ENTRANCE & HEART HOSPITAL WOMEN S CENTER WOMEN S CENTER MAIN ENTRANCE & ORTHOPEDIC CENTER CHILDREN S HOSPITAL HOSPITAL FOR ADVANCED MEDICINE 13 HOSPITAL WITHIN A HOSPITAL CONCEPT 14 HOSPITAL WITHIN A HOSPITAL CARDIOLOGY POPULATION HEART INSTITUTE Cardiology Clinics Non-Invasive Cardiology Interventional Cardiology Cardio-Thoracic Surgery Vascular Surgery, Labs & Clinics HOSPITAL Operating Rooms (12) Acuity Adaptable beds (60) Endoscopy (10) Food Service Shell Floors SHELL 30 Acuity Adaptable Beds 30 Acuity Adaptable Beds SHELL Cardio-Thoracic & Vascular Clinics Cardiology Clinic Interventional Cardiology Surgery Surgery Imaging Non-Invasive Cardiology Food Service 15 HOSPITAL WITHIN A HOSPITAL CONCEPT 16 4

5 MASTER PLAN STRATEGIES ACUITY ADAPTABLE VS. TRADITIONAL MODEL 1 2 Hospital Initiative Aggregate Patients by Disease/Service Line Co-Locate High Acuity Populations Architectural Response Hospital Within a Hospital: The Hospital for Advanced Medicine, The Heart Institute Acuity Adaptable Beds Patient Safety Reduce transfers Reduce medication errors Increase security Patient Quality Aggregate patients by disease/service line Retain nursing care familiarity Improve outcomes ALOS ABIGAIL GEISINGER PAVILION 4W Critical Care Existing (26) Option 1 (19)

6 MED / SURG STUDY INTERMEDIATE STUDY CRITICAL CARE STUDY CRITICAL CARE STUDY

7 ACUITY ADAPTABLE VS. TRADITIONAL MODEL ACUITY ADAPTABLE VS. TRADITIONAL MODEL Staff efficiency Tracked footsteps Staff satisfaction Increase nursing core competencies Staff-friendly environment PATIENT UNIT Building Support PATIENT UNIT Nursing Pods 1:10 Beds HOSPITAL WITHIN A HOSPITAL CONCEPT 27 HOSPITAL WITHIN A HOSPITAL CONCEPT 28 7

8 PATIENT UNIT PATIENT UNIT Family / Visitor Circulation Patient Room Types Staff, Materials, Meds, Patient Transport Circulation Isolation Bariatric Bariatric Isolation HOSPITAL WITHIN A HOSPITAL CONCEPT 29 HOSPITAL WITHIN A HOSPITAL CONCEPT 30 PATIENT UNIT Staff Support Space PATIENT ROOM TYPICAL PLAN HOSPITAL WITHIN A HOSPITAL CONCEPT

9 PATIENT ROOM ISO & BARIATRIC HOSPITAL WITHIN A HOSPITAL CONCEPT 33 GEISINGER HEALTH SYSTEM HOSPITAL FOR ADVANCED MEDICINE 34 MASTER PLAN STRATEGIES ACUITY ADAPTABLE VS. TRADITIONAL MODEL Hospital Initiative Aggregate Patients by Disease/Service Line Co-Locate High Acuity Populations Patient/Visitor/Staff/Student Experience Architectural Response Hospital Within a Hospital: The Hospital for Advanced Medicine, The Heart Institute Acuity Adaptable Beds Patient Centered, Incorporate Families/Staff/ Education Friendly/Wayfinding Guest Comfort Less patient transfers Sleeping accommodations Seating options Lighting options Desk space Wardrobe

10 DESIGN DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? HIGH LEVEL TOPICS/RESULTS: ACUITY ADAPTABLE VS. TRADITIONAL MODEL Planetree Evidence Based Design The Advisory Board Focus Groups System Standards Milcare by Herman Miller casework Exam and Office size similar and standard System Preferences Finishes Materials MASTER PLAN STRATEGIES MASTER PLAN STRATEGIES Hospital Initiative Architectural Response Hospital Initiative Architectural Response 1 Aggregate Patients by Disease/Service Line Hospital Within a Hospital: The Hospital for Advanced Medicine, The Heart Institute 1 Aggregate Patients by Disease/Service Line Hospital Within a Hospital: The Hospital for Advanced Medicine, The Heart Institute 2 Co-Locate High Acuity Populations Acuity Adaptable Beds 2 Co-Locate High Acuity Populations Acuity Adaptable Beds 3 Patient/Visitor/Staff/Student Experience Patient Centered, Incorporate Families/Staff/ Education Friendly/Wayfinding 3 Patient/Visitor/Staff/Student Experience Patient Centered, Incorporate Families/Staff/ Education Friendly/Wayfinding 4 Technology All EMR + Flexible Spaces + State of the Art Chassis 4 Technology All EMR + Flexible Spaces + State of the Art Chassis 5 Model Care Site Visits, Visualization, Mock-ups, Focus Groups

11 SITE VISITS DRAWINGS, SKETCH-UP DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 41 DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 42 LIGHT STUDIES FULL-SCALE MODEL, COMMENTS DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 43 DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 44 11

12 PATIENT BEDROOM FOCUS GROUP HOSPITAL WITHIN A HOSPITAL CONCEPT 45 DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 46 EXPECTATIONS GO/NO GO DECISION TIME TO BEGIN CONSTRUCTION GMC inpatient discharges are expected to grow by approximately 1,400 annually (6% per year) GMC s existing facilities will not be able to accommodate this growth GMC s Volume Accommodation Committee has a portfolio of initiatives to create effective capacity until new facility is available To reach expected levels of performance an additional beds will be needed 47 DO WE WANT TO DO SOMETHING NEW? HOW DO WE DO SOMETHING NEW? 48 12

13 HOSPITAL FOR ADVANCED MEDICINE 1. Team 2. High Level Topics & Results 3. Schedule HOSPITAL WITHIN A HOSPITAL CONCEPT TEAM: TEAM: Acuity adaptable model operational team Steering Steering Physician Administrative Education Monitoring/IT/EMR Building / Integration Ancillary Acuity / Finance Provide administrative oversight and direction regarding the entire process. Physician Provide medical oversight and address medical related issues. Administrative Provide administrative oversight and active participants on all working committees in addition to completing specific work functions. Quality Education Define educational plan to ensure competency of staff when caring for patients at various levels of acuity. They will also provide education for ancillary, department heads, & patients/families

14 TEAM: TEAM: Monitoring/IT/EMR Acuity / Finance Work with MDs and administrators to evaluate, research, determine, and purchase the most appropriate systems for HfAM keeping in mind overall cost weighted against the benefits (efficiency, improved pt. care, improved satisfaction). Building / Integration Develop team strategies that will enhance integration of both units prior to and after opening. Determine the most accurate, feasible, and efficient way to determine staffing based on defined patient acuity. Quality Identify the quality & performance improvement measures that will be monitored on a monthly/quarterly basis. National & local benchmarks will be used for comparative purposes and will be used to provide recommendations for continued improvement. Ancillary Responsible for addressing all issues related to support for HfAM. Dietary, Pharmacy, Respiratory, Laboratory, Environmental Services, Central Sterile/Distribution, Security, Pastoral Services, etc HIGH LEVEL TOPICS/RESULTS: HIGH LEVEL TOPICS/RESULTS: CAPACITY ASSUMPTIONS Acuity Adaptable Model Culture change Calculations Capacity Assumptions Physician Oversight/Coverage Cases (April 2008 March 2009) Inclusion criteria Communication/Execution Plan Discharge Diagnosis Acuity tool Benchmarking Data Actual GHS ALOS / Case Nurse staffing 45 minutes bed cleaning (turn-around time) Nurse education Inefficiency factors applied at 10%

15 HIGH LEVEL TOPICS/RESULTS: INCLUSION CRITERIA CABG & Valve Cases Included in HfAM Liver Transplant Other CT Surgery Ex. Heart assist implant; VSD Thoracic Surgical Vascular Peripheral Vascular Angioplasty Diagnostic Cath Pacers & ICDs Other Surgical Ex: Amputation; vein ligation Medical Cardiology Ex: AMI, Syncope (15%), CP, CHF CHF Observation Long-Term Ventilator Red Critical Care Skills Titrating vasoactive drips; patient w/unstable hemodynamics; (Unstable MI; Cardiogenic Shock; Open Heart Surgery <12 hours; Ruptured AAA repair; Complicated Thoracic surgery; Liver Transplant <24 hours) Orange Critical/Intermediate Care Skills Titrating vasoactive drips; patient stable, but frequent monitoring of hemodynamics. Complicated MI; Open Heart Surgery 12 to 24 hours post-op; STEMI <24 hours; open or ruptured AAA repair to 24 hours post-op; Stable thoracic surgery w/chest Tubes) Yellow Intermediate/Telemetry Care Skills Vasoactive drips but not titrating; hemodynamics stable. (Non-STEMI; Acute Chest Pain; Unstable Angina; Heart Failure w/infusions; Open Heart Surgery hours post-op; Stable thoracic surgery w/ or w/out Chest Tubes) Green HIGH LEVEL TOPICS/RESULTS: ACUITY TOOL Telemetry Care Skills Non-vasoactive drips; Stable hemodynamics and physiologic status. (Non-STEMI patient w/out complications; Heart Failure; Post Cardiac Cath; Open Heart Surgery >36-48 hours) HIGH LEVEL TOPICS/RESULTS: EDUCATION Over 20 hours for every nurse, including; Model of Care / Acuity / Staffing Philips Monitoring / eicu / Vocera / Hill-Rom New Patient Population Central Supply System Ancillary Dept. Functions EMR Documentation Scavenger Hunt Emergency Evacuation Service Excellence Discharge Training CICU staff HIGH LEVEL TOPICS/RESULTS: PHYSICIAN COVERAGE Medical Director Named HfAM P & P Capacity Issues Leads interdisciplinary team to improve quality & safety patient care Meets regularly w / MD and Nursing Leadership Cardiology / Cardiovascular / Vascular / Thoracic Standard service line teams including: Attending Advanced practitioners Residents Hospitalist / Intensivist Intensivist Critical care PA and dedicated Intensivist from 7 am 7pm eicu coverage from 7pm 7am Hospitalist Sweeper service (blue, green, purple) Admitting service (red)

16 HIGH LEVEL TOPICS/RESULTS: COMMUNICATIONS SCHEDULE: Monitoring: Philips Monitor placement & Alarms Overall function Information Technology 30 beds hardwired with eicu equipment on level 7, 15 patient licenses (red and orange acuity level), with ability to expand Intensivist collaboration Communication Vocera Nurse Call Traditional (phones and pagers) Move Day logistics/staffing CICU 7:00AM move begins with the help of: Additional Nursing Staff Respiratory Therapy Lift Team Patient Transport Other volunteers MD s to round before 6:00AM or after 10:00AM 3 rd shift stays to help 1 st shift with the move SCHEDULE: Move Day logistics/staffing AGP4 move begins directly after CICU move All patients will be moved by 3:00PM MD s to round before 10:00AM and identify discharges the evening of Feb, 8th. ACTUAL DATA 1. Benchmarking 2. Satisfaction

17 Principal Diagnosis HfAM 7 Annualized Case Count CICU Cases ACTUAL DATA BENCHMARKING: RESEARCH ACTUAL DATA BENCHMARKING: RESEARCH Coronary Atherosclerosis Native Coronary Artery (41401) Acute Mi Subendocardial Infarct Init Epis Care (41071) Acute Myocardial Infarct Other Inferior Wall Init Epis Care (41041) Aortic Valve Disorders (4241) Acute Myocardial Infarct Other Anterior Wall Init Epis Care (41011) Abdominal Aneurysm Without Mention Of Rupture (4414) Paroxysmal Ventricular Tachycardia (4271) Mitral Valve Disorders (4240) Acute Systolic Heart Failure (42821) 24 8 Other Comps Due Other Card Device Implant &Graft (99672) MSDRG s For Acuity The top 10 admitting diagnosis for the CICU match the cardiac diagnosis for the Acuity Adaptable Unit APACHE IV Score Severity of Illness 46.8 Pre-Implementation Quarter 4 Case Mix Index 3.60 CICU 3.39 FY FY11 Mortality Ratio 1.06 Pre-Implementation Quarter Quarter Quarter Quarter Length of Stay HfAM Level 7 patients stay until discharge from hospital CICU transfer units before discharge st Qtr 2nd Qtr 3rd Qtr 4th Qtr Hfam CICU Central Line BSI per 1000 Line Days ACTUAL DATA ACTUAL DATA BENCHMARKING: RESEARCH Infection Rates Central Line BSI per 1000 device days Zero UTI per 1000 Foley Days Decrease BENCHMARKING: RESEARCH Patient Falls per 1000 Patient Days Decrease UTI per 1000 Foley Days Falls per 1000 Patient Days*

18 ACTUAL DATA BENCHMARKING: RESEARCH ACTUAL DATA BENCHMARKING: RESEARCH Adverse Events Medication Errors per 100 patient days Pressure Ulcer incidence per 1000 Patient Days Decrease Medication Errors Per 100 Patient Days* Pressure Ulcers 1000 Patient Days* ACTUAL DATA BENCHMARKING: RESEARCH Intubation Times and Ventilator Associated Pneumonia (VAP) 2009 average 2.75 days Incidence of VAP (per 1000 device days) Quarter Quarter Quarter Quarter average 2.00 days Incidence of VAP (per 1000 device days) Quarter Quarter Quarter Quarter CICU ACTUAL DATA BENCHMARKING: RESEARCH Staffing Costs Census/HPPD Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 HfAM 7 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Census HPPD Census HPPD

19 ACTUAL DATA BENCHMARKING: SATISFACTION Patient Press Ganey Scores 84.8% before HfAM opened 89.8% now Nursing LESSONS LEARNED VISIBILITY VISIBILITY CRITICAL CARE UNIT GEISINGER MEDICAL CENTER HFAM 6 FULL FLOOR UNIT 75 CRITICAL CARE UNIT GEISINGER MEDICAL CENTER HFAM 6 POD UNIT 76 19

20

21 81 82 Thank You. For More Information: Natalie Miovski, AIA, LEED AP Principal, Healthcare Architect M. Kate Fleetwood, MHSA, SSBB Project Manager, Administration EwingCole PHONE: Geisinger Health System PHONE: