Customized ER Operational Strategies. Kirk Jensen, MD, MBA, FACEP Jody Crane, MD, MBA, FACEP Kevin Nolan, MStat, MA. Session Objectives

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1 Session A18/B18 This presenter has nothing to disclose Customized ER Operational Strategies for Low Acuity Patients Kirk Jensen, MD, MBA, FACEP Jody Crane, MD, MBA, FACEP Kevin Nolan, MStat, MA 1 Session Objectives Participants will be able to: 1. Describe strategies based on ER volume that can be implemented in your ER to efficiently treat low acuity patient (i.e. Levels 4, 5 and some 3s). 2. Identify specific models and elements of design that could and should be applied in your ER. The presenters have nothing to disclose 2 1

2 Session Topics 1. Overview and setting context 2. Flow models for low acuity patients 3. Key elements of design for low acuity patients 3 Why are we doing this? 4 2

3 Timeliness of care has a strong correlation to patient satisfaction (1,2) with wait time to be treated by a physician having the most powerful association with satisfaction. (3) 1. Bursch B, Beezy J, Shaw R. Emergency department satisfaction:what matters most? Ann Emerg Med. 1993;22: Thompson DA, Yarnold PR, Williams DR, et al. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28: Boudreaux ED, D Autremont S, Wood K, et al. Predictors of emergency department patient satisfaction: stability over 17months. Acad Emerg Med. 2004;11: Kirk B. Jensen, MD, MBA, FACEP Quality and Safety Average Claims / 25k patient visits minutes minutes > 60 minutes Time to Physician Source: Studer Group and CEP 6 3

4 LOS (in Hours) Effect of Working on Low Acuity Patients Error bars represent 95% Confidence Intervals for Mean LOS 2.25 Baseline SCENARIO NUMBER ESI 2 ESI 3 ESI 4 X ESI 5 Why Designs for Low Acuity Patients Fail Unclear mission Entry criteria poorly defined Lack of dedicated (and committed) staff Capacity and demand mismatches Staff, space, supplies.. Missing the ramp up Multiple handoffs Too sick patients Standardization failures 8 4

5 Standard Work Mindless conformity and the thoughtful setting of standards should never be confused. What solid Standard Operating Procedures do is nip common problems in the bud, so that staff can focus instead on solving uncommon problems. Bill Marriott (of the Marriott hotel chain) as quoted by Mark Graban in Lean Hospitals Kirk B. Jensen, MD, MBA, FACEP 9 Standard Work 10 5

6 The Importance of Standard Work Standard Work/Documentation Roles, Evidence Based Practices In low acuity patients, this may be more about process documentation than evidencebased practices, making sure everyone understands their roles and work sequence Pain protocols and frequent flier pathways may be implemented and adhered to here Certain evidence based practices such as antibiotic practices and influenza pathways certainly have a role Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, Design Targets for Low Acuity Patients Gold standard for LOS is 60 minutes or less, but hard to achieve. A median LOS for all low acuity patients (4,5, some 3 s) < 75min should be considered excellent The average is somewhere in the 90 minute to 120 minute range. As far as ideal throughput time, controlling for quality and safety, the shorter the better from the patient's perspective. 12 6

7 The EDBA Annual ED Data Survey 2011 Results for 830 EDs Hi CPT Under Admit % Transfer EMS EMS Median MLOS Treat MLOS LBTC Door EKG seeing 29.6m pts Acuity age 18 % Arrival Arrival Admit LOS & Release Admit to Doc per 100 Over 100K 66% 20.2% 21.8% 0.9% 23% 42% % to 100K 71% 18.4% 20.9% 1.1% 21% 44% % to 80K 66% 18.2% 20.8% 1.2% 19% 44% % to 60K 65% 19.5% 19.1% 1.4% 18% 43% % to 40K 63% 20.2% 17.1% 1.8% 16% 41% % Under 20K 55% 23.7% 12.7% 2.7% 12% 39% % Pediatric 48% 99.0% 11.4% 0.6% 8% 33% % 31 4 Adult, Specialty 71% 2.7% 25.5% 1.1% 23% 48% % Urgent Care, Freestanding 41% 23.6% 4.2% 3.4% 7% 31% % Data from the Emergency Department Benchmarking Association (EDBA) 13 General Principles The front door and your front end processes drive flow. Triage is a process, not a place. Get the patient and the doctor together as quickly and efficiently as possible. Fast track is a verb, not a noun. Keep your vertical patients vertical and in motion. For horizontal patients, real estate matters. For vertical patients, speed matters. We want to be fast at fast things and slow at slow things. Kirk Jensen/Thom Mayer/ Jody Crane 14 7

8 15 Front End Patient Flow: A Portfolio of Options Advanced Triage Orders/Treatment Protocols Fast Tracking Low Acuity Patients: Super Track (ESI 5 s + simple 4 s) Fast Track (ESI 5 s, 4 s, and simple 3 s) Clinician in Triage Rapid Medical Evaluation (RME) Midlevel Provider in Triage MD in Triage Intake Team/Team Triage (multi disciplinary assessment and treatment team) 16 8

9 Front End Patient Flow: A Portfolio of Options Advanced Triage Orders/Treatment Protocols Fast Tracking Low Acuity Patients: Super Track (ESI 5 s + simple 4 s) Fast Track (ESI 5 s, 4 s, and simple 3 s) Clinician in Triage Rapid Medical Evaluation (RME) Midlevel Provider in Triage MD in Triage Intake Team/Team Triage (multi disciplinary assessment and treatment team) A Portfolio of Options available to be set up as patient volume and demand either requires it or can justify it. The front end flow tactics(s) are selectively and scientifically deployed at certain hours of the day and days of the week based upon your demand capacity modeling of incoming patient flow. 17 Models for Low Acuity Patients 18 9

10 Super Track A Fast Track located in or near triage for the purpose of promptly treating patients who require very low resource utilization Entrance/Exit 1 Doc/MLP 1 RN/LPN 1 Tech Treatment Room 1 Treatment Room 2 Procedure Chair Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 2011 Results Waiting Super Track Volume Bands 2011, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 10

11 Rapid Medical Evaluation (RME) Midlevel Provider in Triage MD in Triage Intake Team (multi disciplinary assessment and treatment team) 21 One STOP shopping 1. Keep area open, visible to all 2. Keep patients upright 3. Keep all equipment /manpower mobile 4. Each station has to be user friendly Kirk B. Jensen, MD, MBA, FACEP 22 11

12 Intake System Quick Look Quick Reg Team of providers that promptly assess, treat, and discharge primarily level 3 patients Quick Triage 2 Providers (Doc/MLP), 2 RN/LPN,1 Paramedic 2 Scribes, 1PSR/HUC 5 Rooms Treatment Area Results Waiting Intake Volume Bands 2011, Jody Crane, MD, MBA, Charles E. Noon, Ph.D

13 General Operational Strategies for Low Acuity Patients by Volume 20,000 No triage, Immediate bedding, bedside registration for all No Segmentation Clear signals to identify low acuity patients Results waiting 40,000 Quick Look Triage to segment, Quick/Bedside Registration for all For ERs with low acuity/low admit: Super Track (9a 11p) with 1 2 MLP with committed resources for lab/rad For ERs with high acuity/high admit: Intake Team (9a 11p) with 1 doc, 1 MLP with committed resources for lab/rad Results waiting 60,000 Quick Look Triage to segment, Quick/Bedside Registration for all Super Track (8a 1a), MD/MLP Intake Team (9a 11p) Results waiting 25 Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 2011 From Models and Strategies to DESIGN: Key Elements of a Design for Low Acuity ER Patients 1. Profile of patient demand by hour of the day 2. Average service times required to match demand 3. System for patient segmentation 4. Distinct processes for low acuity patients 5. Right staffing mix 6. Contingencies for large fluctuations in demand or capacity Matching Your Demand: Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

14 1. Profile of low acuity patient demand by hour of the day You should know your arrivals by hour of day Busy and slow days Broken down by Chief complaint ESI Level Ancillary Utilization Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, Average Low Acuity Service Capacity (bed, doc, nurse) required to match demand This can be expressed in 1) patients per hour or 2) in terms of how much time you have and how much time it takes. 1. If 3 low acuity patients are coming through per hour, and your service rate is 2.5 patients per hour, then you have some work to do. 2. Similarly, if 3 low acuity patients are coming through per hour, then you have 20 minutes per patient. If it takes you 24 minutes, you must improve your process Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

15 Scientific Management: Matching Capacity to Demand Arrivals vs. Staffing (MD and MLP coverage) 5 Demand vs. Capacity MinorCare 4 Demand vs. Revised Capacity MinorCare - Heavy Days :00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Modeled Demand Average Demand Capacity Average Demand Modeled Demand Capacity 29 Matching Capacity to Demand Arrivals vs. Staffing Efficiency and Effectiveness Inefficient Allocation Example: 96 Nursing Hours Efficient Allocation Example: 96 Nursing Hours Nursing Demand 3 4 Nursing Demand Demand Inefficient Allocation Demand Efficient Allocation 30 15

16 3. System for Patient Segmentation Getting the patient to the right place, at the right time, with the right treatment Patient Enters Patient Sorted Sick Not Sick Doctor To see Now Streamlined Care ST/FT/TT/RW Immediate bedding in back System for Patient Segmentation ESI Based 4 s, 5 s, and criteria based level 3 s Age criteria CC criteria Other Triage Scale CTAS Manchester ATS (Australia) Historical Resource Utilization Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

17 3. System for Patient Segmentation NOTE: If your processes are the same, segmentation will actually hurt your overall system performance due to anti pooling Triage Brief RN Assessment: ESI Evaluation / Evaluation of Acuity High Acuity Pathway ESI Levels Moderate Acuity Pathway Most ESI Level 3s Low Acuity Pathway ESI Levels 5, 4, + some 3s 33 Emergency Streaming: an example RN 3. System for Patient Segmentation/ distinct area in ED to treat specific patient 15 20% Super Track ESI % Intake/PODs ESI % Main ED ESI , Crane, Noon, Leitner 34 17

18 Standardize! Who is Appropriate for Low Acuity? 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D Distinct Processes for Low Acuity Patients All processes should be designed with Flow in mind. Consider: Medications Radiology and lab services Point of use supplies Point of care testing Visual signals Results waiting Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

19 4. Distinct Processes: Medications that can be given in intake Standardize! Stick with PO meds primarily PO pain meds OK Nebs OK IM injections OK, but stick with non narcotics No IV s unless the patient is heading towards a treatment area, no IVF 2011, Jody Crane, MD, MBA Distinct Processes: Radiology and Lab Services for the Front End and Triage Lab and radiology should have easy, reliable access to patients. They should be located near triage and fast tracking area if possible to promote patient flow. Phlebotomy should be available at triage Transporters are underutilized, underappreciated, and should be employed 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D

20 Super Track Ancillaries Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, Distinct Processes: Point of Use Supplies Should have a system in place such that supplies are readily available Commonly used supplies should be close to the point of use, quickly accessible b lood tubes, medications fluids, CT supplies(contrast) pelvic exam equipment Can be set-up and charged outside of the patient care window Can be determined by chief complaints of patients targeted for FT 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D

21 4. Distinct Processes: Point of Care Testing I Stat 3 min (H/H, Chem 8, CKMB,Trop I, BNP, PT/INR, ABG, Lactate ) Biosite 10 min Myoglobin, Ck MB, Trop I, BNP, D dimer Clinitech 2 min U/A, UPT Piccolo 12 min BMP, CMP, Electrolytes Chempaq POC CBC with diff! Rapid strep, mono, influenza 2012, Jody Crane, MD, MBA Distinct Processes: Visual Signals Signals indicating the patient status in the room, signals on the floor to indicate the path patient should take for lab or x ray 2012, Jody Crane, MD, MBA 42 21

22 Visual Signals The goal of visual signals/visual controls is to make performance, waste, problems, and abnormal conditions readily apparent to employees and managers Distinct Processes: Results Waiting Should be available close to triage Used to buffer long Rad/lab TAT without consuming bed resources Need an eye on this area Should be designed with customer service as #1 thought Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

23 Standardize! Who is eligible for Results Waiting? There are many variation depending on how elaborate the RW area is Ambulatory Should need very few interventions Very low risk No etoh, homeless, etc Can get more elaborate in the right settings: IV narcotics after observation period IV abx after observation period 2011, Jody Crane, MD, MBA 45 Results Waiting Can be internal or external External usually back out to the ED waiting room Advantages limitless capacity, already triage nurse eye on area Disadvantages patients can wander, poor visibility, patient satisfaction Internal Advantages patients feel they are in process, dedicated supervision Disadvantages space limited Should be entertaining and comfortable 2009, Jody Crane, MD, MBA 46 23

24 If an Airport can do it 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 47 If an Airplane can do it Picture compliments of Jim Lennon, Arch 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D

25 5. The right staffing mix/skill mix/training For most low acuity patient populations, midlevel staffing is preferred Low cost Right skill mix Little risk of rework or physician intervention Exceptions would be If your docs have to see every midlevel patient prior to discharge If you do not have sufficient volume of low acuity patients to justify a segmented stream Volume and acuity justify the full deployment of a physician upfront Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, Contingencies for large fluctuations in demand or capacity For low acuity areas, you Low want high utilization; therefore, Acuity there is not much room for surge. EDs should be designed with progressively more capacity as the acuity level increases As such, low acuity should be able to spill over into mid acuity areas and mid acuity to high as a general rule Mid Acuity High Acuity Kirk Jensen, MD, MBA and Jody Crane, MD, MBA,

26 In Summary: Improving Flow for Low Acuity ER Patients Select models and strategies based on volume/demand Focus on Design 1. Profile of patient demand by hour of the day 2. Average service times required to match demand 3. System for patient segmentation 4. Distinct process for low acuity patients 5. Right staffing mix 6. Contingencies for large fluctuations in demand or capacity Standardize! 51 Questions to Consider on Your Way Home If you could do three things to either improve your Emergency Department, or improve your ability to improve your Emergency Department, what would they be How can your ED, your Team and your Hospital best work together to What are your next action steps 52 26

27 Resources, References, and Benchmarking 54 27

28 Improving Patient Flow In the Emergency Department Kirk Jensen/Jody Crane 55 Hardwiring Flow Systems and Processes for Seamless Patient Care Thom Mayer, MD, FACEP, FAAP Kirk Jensen, MD, MBA, FACEP Why patient flow helps organizations maximize the Three Es : Efficiency, Effectiveness, and Execution How to implement a proven methodology for improving patient flow Why it s important to engage physicians in the flow process (and how to do so) How to apply the principles of better patient flow to emergency departments, inpatient experiences, and surgical processes 56 28

29 The Definitive Guide to Emergency Department Operational Improvement Jody Crane MD MBA (Author), Chuck Noon PHD (Author) 57 Leadership for Smooth Patient Flow: Improved Outcomes, Improved Service, Improved Bottom Line Kirk B. Jensen, MD, FACEP Thom A. Mayer, MD, FACEP, FAAP Shari J. Welch, MD, FACEP Carol Haraden, PhD, FACEP The heart of the book focuses on the practical information and leadership techniques you can use to foster change and remove the barriers to smooth patient flow. You will learn how to: Break down departmental silos and build a multidisciplinary patient flow team Use metrics and benchmarking data to evaluate your organization and set goals Create and implement a reward system to initiate and sustain good patient flow behaviors Improve patient flow through the emergency department the main point of entry into your organization The book also explores what healthcare institutions can learn from other service organizations including Disney, Ritz-Carlton, and Starbucks. It discusses how to adapt their successful demand management and customer service techniques to the healthcare environment. This book marks a milestone in the ability to explain and explore flow as a central, improvable property of healthcare systems. The authors are masters of both theory and application, and they speak from real experiences bravely met. Donald M. Berwick, MD President and CEO Institute for Healthcare Improvement (from the foreword) ACHE + Institute for Healthcare Improvement 58 29

30 The Hospital Executive s Guide to Emergency Department Management Kirk B. Jensen, MD, FACEP Daniel G. Kirkpatrick, MHA, FACHE Introduction: Why the ED Matters 1. A Design for Operational Excellence 2. Leadership 3. Fielding Your Best Team 4. Improving Patient Flow in the Emergency Department 5. Customer Service: Ensuring Patient Satisfaction 6. ED Change Initiatives: Getting Things Done 7. ED Change initiatives Managing Change 8. Patient Safety and Risk Reduction 9. The Role and Necessity of the Dashboard 10. How the ED Is a Business 11. Billing, Coding, and Collections 12. Physician Compensation Models Productivity Based Systems HcPro ISBN: The Improvement Guide and Rapid-Cycle Testing Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey Bass Publishers;

31 References Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C Christensen, C, J Grossman, and J Hwang. The Innovator's Prescription: A Disruptive Solution for Health Care Full Capacity Protocol. Goldratt, E. The Goal. Great Barrington, MA: North River Press, Holland, L., L. Smith, et al Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay. Am J Clin Pathol 125 (5): Husk, G., and D. Waxman Using Data from Hospital Information Systems to Improve Emergency Department Care. SAEM 11(11): Jensen, Kirk. Expert Consult: Interview with Kirk Jensen. ED Overcrowding Solutions Premier Issue. Overcrowdingsolutions.com Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130: Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; (Available on Wilson, M., and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America s Emergency Departments. Urgent Matters White Paper. September, Benchmarking Resources Where to find data Your neighbors Call and/or visit ACEP Premier VHA ED Benchmarking Alliance UHC Be sure to compare hospitals with similar acuity and similar volume 62 31