From Admission to Home: Redesigning the Hospital Experience Michelle James James Lee Joanne Roberts Linda Severs
Learning Objectives Culture of Collaboration Team engagement across organizations Seamless patient care
Common Service Area Snohomish County
Services Overview Providence Regional Medical Center 275,000 visits annually 00,000 ED Visits annually 49 licensed beds with 26,500 patient admissions annually The Everett Clinic 850,000 visits annually 70,000 Walk-in Clinic visits annually 3 Ambulatory Surgery Centers Second largest private employer in Snohomish County 900 medical providers 45 hospitalists (Everett Clinic) Fifth largest private employer in Snohomish County 45 healthcare providers 35 physicians
Great Organizations, Great Care Providence Regional Medical Center Everett HealthGrades: 2007-200 Distinguished Hospital Award for Clinical Excellence The Everett Clinic Fortune 00 Best Company to Work For Island of Excellence - CMS
The Everett Clinic Our Core Values: We do what is right for each patient. We provide an enriching and supportive workplace. We strive to improve & provide value: quality, service and cost.
Providence Regional Medical Center Everett Providence Health & Services Mission: As people of Providence, we reveal God s love for all, especially the poor and vulnerable, through our compassionate service. Vision: Together, as people of Providence, we answer the call of every person we serve: Know me, care for me, ease my way. 7
Secret Ingredients - All About Patient Care Trust Leadership doing what is right Transparency Collaboration Seamless care model (people/processes) Learning Lean outside healthcare Competition Being the best in healthcare means working together
Trust Developing community Hospitalists program with Everett Clinic management: Medical team Surgical team Neurological team Orthopedic team Everett Clinic physicians have been active in Providence leadership: Chief of Surgery Chief of Medicine Chief of Ambulatory Care
Collaboration Hospitalist program Kaizen: from admission to home Providence Regional Cancer Care Partnership Palliative Care Oncology Primary Care Inpatient Consult
What is Kaizen? Improve Harmony
Sharing the Idea with Our Team
Key Leadership Moments Set Expectations You work as a team Demand Transformation Widen your comfort zone Get Senior Leadership Support Be our sponsors! Collaborate with Health Plan We need your data
Introduce Kaizen Work - Focus on Adding Value Identify value from the patient s view Uncover waste in our current processes from all perspectives Identify areas of unbalanced work Find hidden capacity in the system Explore together across the continuum
Discuss Patient/Family Expectations The Ideal State 7 6 5 4 3 2 0 Clinical Outcome/Quality and Safety Compassionate Care/Customer Satisfaction Coordinated Care/Best Work Place Affordability/ Secure Future Leadership Input Patient and Family Representative Input
Align and Translate Values Across Stakeholders Providence Everett Clinic Customers: Primary: Patients and families Secondary: Bedside care team Clinical Outcome Outcome driven Quality and Safety Outcome driven Creating best practice community standards Compassionate Care Customer Satisfaction Easy button for each patient and care provider Coordinated Care Seamless care continuum Affordability Adding Value Best Work Place Seamless care continuum Secure Future Adding Value Improve communication and reduce breakdown during admission process Eliminate waste Potential Opportunities Improve discharge transition Improve patient satisfaction Decrease diversion during admission process from Clinics to ED ED to non-providence hospitals Develop clinical checklist on: Admission criteria Appropriate imaging Labs
Create A Common Vision An integrated healthcare community delivering patient and family-centered care through compassion, excellent outcomes, innovation and value to ensure a world-class future.
Over 50 Hours of Observation Uncover Waste and Unbalance Intake # Follow Up #0 Admit #2, 3, 4 Patient Journey Post Acute #9 Care TX #5, 6, 7 Number of Process Step Number Staff Observed Patients Observed - Registration 5 0 2 - Non ED Admit 3 3 3 - Bed Assignment 30 0 4 - Admit from ED 42 2 5 - Rounding 6 30 6 - Coordination of Care 0 30 7 - Discharge Planning 5 8 8 - Discharge Process 25 9 9 - Information Flow 3 3 0 - Follow Up Visit 40 Totals 40 65 Discharge #8 Over 50 hours of direct observation
Value-Added Time Process Process Time (min) Value Added (min) Value Added (%) Registration 6 0 0 Admit (Direct) 72 4.4 20 MD Admission 66.2 7.2 26. RN Admission 43 237 57.2 MD Round (F) 47. 9.9 2.0 MD Round (R) 35. 7.0 9.9 MD Round (L) 42.9 5. 0.3 RN Discharge 8 4.7 8. Post DC RN Call 2 2 6.7 Evaluated and categorized each step of the process Identify Value Added or Non Value Added processes from the Patient s perspective Only 20% Value Added!
Our Week Long Event Day One Intro/sponsors Vision: today and 5 years Review current-state VSMs Day Two Current-state VSMs Patient and family panel Lean lessons: where is the waste? Day Three Envisioning the ideal state The future state Day Four Sponsor feedback Plans for 200
Strategic Objectives Key objectives set by patients and families: Office to hospital bed no delay Tell my story as few times as possible Communication entire care team on the same page No surprises in process or outcome during the hospitalization Transition education around Four Pillars (Coleman)
Some Landmarks on the Ideal Map Open access clinics Information flows with patient Open access beds The team awaits Movement toward patients & families Discharge at admission Guides along the way
Picturing the Ideal State Deliver services to patients in their rooms when at all possible - rather than transport patients to services.
Uncover Waste Transition Management Scope: Admission to Home Transition In Transition Within Transition Out
Colby Campus Transformation Stats 200 Stories 2 Size Height Construction Cost tower Additional Costs parking garage, technology, renovations Number of licensed acute beds (in tower) 700,000 sq. ft. 75 feet $500 million $00 million 240 Opening Date June 20 25
Transition In - Overview Improve Direct Admit Process One call does it all Integrated care team greets patient Focus on patient and family centered care Appropriate bed designation Observation vs. inpatient status
Individual Value Transition In Direct Admission Process Project Goal: Reduce call to bed placement time; one call does it all Enhance patient experience upon arrival to PRMCE right place and right time Getting There: Series of facilitated meetings with key stakeholders to identify issues, discuss objective data, generate solutions and develop action plans for implementation. Outcomes: I-MR Chart of LS Call to Assigned Calc by Code (=PreImprove; 2=PostImpro 450 300 50 0 2 _ UC L=53.4 X=3.7 LC L=-26.0 Mean Median 3.7 min 6. min 25 249 373 497 62 Observation 745 869 993 7
Transition In Observation vs. Inpatient Project Goal: Add value to patient care via: Increase appropriate use of observation status Reduce length of stay for observation patients Getting There: Health plan utilization data Hospitalists and care coordinators develop simplified checklist Transparent report at provider s level Outcomes: Baseline 6 Months Obs/Obs+Inpatient 24% 32% Obs Discharge <24 hours 47% 54%
Sharing Data at Provider Level January-July 20 Percentage of Observation Admissions Wang, W n=8 Meyers, D n=29 Staudinger, B n=68 Roberts, J n=0 Moe, S n=86 Chiou, L n=20 Bradley, S n= Wescott, S n=89 Sutcliffe, E n=58 Pacifico, A n=59 Hart, K n=63 Koh, J n=67 Moser, A n=63 Nysoe, T n=59 Fox, A n=99 Lee, K n=7 Pilmer, G n=98 Pandrea, A n=24 Kim, T n=45 Hobbs, J n=58 Brownstein, A n=64 Spencer, T n=33 Ali, S n=86 Tsai, J n=55 Kneeland, P n=54 Beckley, R n=46 Winningham, J n=29 Alanis, L n=42 Cramer, J n=26 Santiago, C n=25 Rafii, C n=49 Chen, A n=56 Wroblewski, K n=8 Lee, E n=38 Cheng, R n=82 Wright, A n=37 Smith, M n=53 Rocca, P n=04 Lau, G n=40 Johnson, A n=77 Lin, D n=53 Perez, C n=97 Hu, K n=3 Rideout, A n= Figenshaw, S n=3 Howry, K n=0 Hayden, S n=0 Golob, A n=0 Derksen 9/7/20 0% 0% 0% 7% 4% 48% 46% 45% 42% 42% 4% 4% 40% 40% 39% 39% 39% 38% 37% 37% 35% 35% 35% 35% 34% 33% 33% 33% 32% 3% 3% 3% 3% 3% 30% 30% 30% 29% 28% 28% 27% 26% 26% 25% 25% 0% 0% 20% 30% 40% 50% 60% 70% 80% 90% 00% 54% 69% 89%
Transition Within - Overview Using work from the transition in phase, as well as a new bed tower to drive the urgency, hospitalists, nurses and discharge planners committed to working as a team with patients and families: Hospitalist deployed by patient care unit Daily management system daily patient huddles Risk of readmission classification MD/RN rounding
Transition Within Example Setting the Care Plan Project Goal: Enhance collaboration across the care team (geographic placement of care teams) Proactive discharge planning Getting There: Series of facilitated meetings with key stakeholders to identify issues, discuss objective data, generate solutions and develop action plans for implementation. Outcomes: 00 90 80 70 60 50 40 30 20 0 0 64 60 63 Team Compliance % 79 88 90 89 87 93 Initial Goal = 75% 00 90 80 70 60 50 40 30 20 0 0 Start of Collaborative Care Median LOS 2 3 4 5 6 7 8 9 0 2 200 20 Estimated 20
Transition Out - Overview Using information from IHI, other published resources and the TEC-sponsored consultative work of Eric Coleman (Care Transitions Intervention) teams now are seeking to ensure: Proactive planning for discharge upon admission Expectations of hospital discharge established upon admission Community-wide commitment to five-day follow-up in primary care offices after hospitalization Tighter clinical integration with core skilled care facilities
Transition Out Discharge Transitions Project Goal: Streamline day of discharge for improved patient and staff satisfaction Start planning for discharge upon admission Getting There: Series of facilitated meetings with key stakeholders to identify issues, discuss objective data, generate solutions and develop action plans for implementation. Outcomes: Outcomes:
To Learn More About Everett Correspondent T.R. Reid confers with the authors of the Dartmouth Atlas of Health Care and learns that there are huge variations in health care spending across the US. Traveling coast to coast, he finds doctors and hospitals (in Everett, WA) that are working hard to provide excellent health care at reasonable cost. PBS Documentary - "U.S. Health Care: The Good News," T.R. Reid http://www.pbs.org/programs/us-health-care-goodnews/
Questions & Discussion