Ensuring Flow and Access. Todd May & Jim Marks

Ensuring Flow and Access Todd May & Jim Marks

TRUE NORTH 2

Ensuring Flow and Access 3

BACKGROUND & PROBLEM STATEMENT Z S F G h a s w r e s t l e d w i t h b r o k e n f l o w f o r m a n y y e a r s I n F Y 1 5-1 5 i m p r o v i n g f l o w p a r t o f s t r a t e g i c p l a n Wo r k f o c u s e d i n E D, i n p a t i e n t u n i t s, U C C R e d u c e E D L O S, LW B S, inpt., L O S. D / C b y n o o n, 3 o f L L O C p a t i e n t s O n l y g o a l t o h i t t a r g e t w a s LW B S f r o m 8. 3 % t o 5. 9 % N e e d t o f o c u s o n a l i g n m e n t a n d p r i o r i t i z a t ion Poor flow of patients throughout ZSFG results in long wait times and poor access to healthcare for our patients, impacting all True North pillars 4

Current state/future state Defined by a series of mathematical equations relating capacity need to volume and LOS

Current State January 2017 Points of Entry 166 48 Walk-ins Ambulances Current state/future state Diversion 67% ESI 4/5 32% ESI 1/2 30% ESI 3 38% Emergency Dept Capacity of 59 24-30 10-12 19-30 6.6% 13 High and moderate acuity Low acuity Admitted Patients LWBS Bed Deficit ED Backed Up 34.1 pts/ day admitted 102 54 39 patients 33% 28 Inpatient Stays Capacity of 164 Med-Surg Medium Stays Med-Surg Short Stays (1.4 days) Lower Level of Care Short Stay / Unnecessary Admissions Bed Deficit High Diversion Rate 67% High Short Stays High Lower Level 28 Total Bed Deficit ED Backed Up Future State January 2018 158 Points of Entry 57 Walk-ins Ambulances Diversion 30% ESI 4/5 21% ESI 1/2 33% ESI 3 46% Divert 26 ESI 4/5 pts to Urgent Care/ Primary Care Emergency Dept Capacity of 59 25-27 4-5 7-9 3.0 % LWBS 19-23 High and moderate acuity Low acuity Admitted Patients Bed Excess ED Not Backed Up 24.1 pts/ day admitted Place LLOC Pts Observation Unit 8 patients Root Cause 136 7 <10 4% 11 Inpatient Stays Capacity of 164 Med-Surg Medium Stays Med-Surg Short Stays (1.4 days) Lower Level of Care Short Stay / Unnecessary Admissions Bed Excess Low Diversion Rate 30% Reduced Short Stay Reduced Lower Level 11 bed excess ED not Backed up Providing care in the wrong place

Four key countermeasures No. Root Cause Countermeasures Just Do It 1-3 Months 3 Month Milestone 3-6 Months 6-12 Months 1. Non-acute patients occupying acute care (preventable hospital bed-days) Decrease and Maintain lower level of care (LLOC) patients to <10 L Holpit devoting substantial time to Care Coordination leadership Social Workers assigned to each inpatient team Develop Operational A3 May/Dentoni Exec Sponsors McIntyre/Holpit Daily accurate data No. of patients Discharge destination Barriers Next steps Weekend staffing PDSA LLOC A3 Achieve maximum 10 LLOC patients at ZSFG Analysis of PDSA LLOC A3-SR Maintain maximum 10 LLOC patients at ZSFG (TN goal) 2. Short stay and nonacute patients admitted to acute care hospital (preventable admissions) Lower Hospital Admits by Establishing CDU /Observation Unit Pilot Flow Director / Coordinator position Jeff S/Terry D Develop Operational A3 Dentoni/Marks Exec Sponsors Malini/Ranji Visit UCSF CDU--done PDSA Virtual CDU in ED CDU A3 Analysis of PDSA Virtual CDU Establish CDU at 6 months Decrease shortstay admits by > 5/day CDU utilizes 80% of designed capacity 3. Lower acuity patients who could be seen elsewhere are seen in the ED (preventable ED visits) Divert 26 ESI 4/5 patients /day from Emergency Department to Urgent Care Center or Primary Care Meet with Urgent Care and Call Center to discuss capacity and standard work to refer patients from ED (ensure compliance with EMTALA ) Develop Operational A3 Boyo/Williams Exec Sponsors Labuguen/Singh/ Ferrer/Day PDSA Referrals to UCC Lower Acuity patient A3 Divert 5 patients/ day to Urgent Care Center or Primary Care Lower Acuity patient A3-SR Prepare for UCC move Divert 26 patients/ day to Urgent Care Center or Primary Care 4. Admitted patients are boarded in the ED due to lack of hospital Decrease Emergency Department length of stay for non-fast track patients Develop Operational A3 Marks/Williams Exec Sponsors Ortiz/Mercer/ Staconis/Holpit ED LOS Reduction A3 Analysis of PDSA Hallway Admits ED LOS reduction A3-SR Achieve TN goal for average ED length of stay (275 min) PDSA Hallway Admits: Terry/Todd 7

Mean ED LOS 2018 Scorecard: Hospital Wide Focus 2018 Target: 275.0 True North: QUALITY Yr End % Improvement: 20.1% Year Measure Of: Minutes to Date Owner: May, Marks, Dentoni, Williams 2017-18 Baseline: 344.0 Reduce ED mean length of stay to 275 2018 YTD: 342.7 minutes by December 31, 2018 YTD % Improvement: 0.4% TARGET AND GOALS Ambulance Diversion Rate 2018 Scorecard: Hospital Wide Focus 2018 Target: 40% True North: QUALITY Yr End % Improvement: 30.6% Year Measure Of: Percentage of Time to Date Owner: May, Marks, Dentoni, Williams 2017-18 Baseline: 57.6% Reduce ED Ambulance Diversation rate to 2018 YTD: 52.9% 40% by December 31, 2018 YTD % Improvement: 8.1% 390 385 80.0% 370 350 330 310 353 363 350 342 346 354 301 344 328 324 334 351 335 363 341 312 317 70.0% 60.0% 50.0% 67.0% 68.0% 59.9% 48.6% 47.7% 52.6% 52.8% 52.8% 55.0% 52.7% 59.1% 48.7% 57.3% 54.3% 46.5% 52.9% 290 270 250 Target 275 min 40.0% 30.0% 34.1% 42.3% Target 40% 230 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun 20.0% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Mean ED LOS YTD Mean ED LOS Target Baseline Number of LLOC patients 2018 Scorecard: Hospital Wide Focus 2018 Target: 300.0 True North: QUALITY Yr End % Improvement: 76.1% Year Measure Of: # LLOCDays/month to Date Owner: May, Marks, Dentoni, Williams 2017-18 Baseline: 1253.0 Reduce number of LLOC days/month to 300 2017-18 YTD: 1239.2 by December 31, 2018 YTD % Improvement: 1.1% Diversion Rate YTD Diversion Rate Target Baseline PRIME Readmission Rate 2018 Scorecard: Hospital Wide Focus 2018 Target: 14.3% True North: QUALITY Yr End % Improvement: 1.1% Year Measure Of: Percentage of Readmissions to Date Owner: May, Marks, Dentoni, Williams 2017-18 Baseline: 14.5% Reduce hospital readmissions rate to 15.04% 2017-18 YTD: 14.2% by June 30, 2018 YTD % Improvement: 1.9% 15.50% 1,600 1,400 1,200 1,000 800 600 400 1,015 1,271 1,475 1,515 1,420 1,235 1,388 1,081 1,361 1,296 1,277 1,150 1,085 1,104 1,092 914 Target < 300 days 1,387 15.00% 14.50% 14.00% 13.50% 15.14% 14.85% 14.71% 14.73% 14.69% 14.63% 14.55% 14.55% 14.48% 14.42% 14.34% 14.28% 14.30% 14.21% Target 15.04% 14.10% 13.94% 13.96% Target 14.32% 200-13.00% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May LLOC patient days/month YTD LLOC patient days/month Target Baseline Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Readmissions Rate Target Baseline 8

2017-18 ACHIEVEMENTS: Reducing social admissions Admissions averted Averted Admissions & Readmissions From Jan-May 2018 ZSFG s Social Determinants of Health Work has: Averted 115 inpatient social admissions Prevented 22 readmissions PRIME Readmission Rate 2018 Scorecard: Hospital Wide Focus 2018 Target: 14.3% True North: QUALITY Yr End % Improvement: 1.1% Year Measure Of: Percentage of Readmissions to Date Owner: May, Marks, Dentoni, Williams 2017-18 Baseline: 14.5% Reduce hospital readmissions rate to 15.04% 2017-18 YTD: 14.2% by June 30, 2018 YTD % Improvement: 1.9% 15.50% 15.14% Reduced ED Utilization and Inpatient LOS Avg ED visits 60 days prior to intervention: 2.40 Avg. ED visits 60 days post intervention: 2.17 Avg. IP LOS prior to intervention: 6.2 Avg. IP LOS post intervention: 5.3 15.00% 14.50% 14.00% 13.50% 13.00% 14.85% 14.71% 14.73% 14.69% 14.63% 14.55% 14.55% 14.48% 14.42% 14.34% 14.28% 14.30% 14.21% 14.10% 13.94% 13.96% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Readmissions Rate Target Baseline 9

2017 LESSONS LEARNED: Seasonal surging of hospital capacity reduces ED LOS and ambulance diversion FY 15-16 Scorecard: ZSFG Year to FY 15-16 Target: 35% Date True North: Care Experience Yr End % Improvement: 18.2% Measure Of: Access and Flow (%) Owner: TD&JM FY 14-15 Baseline: 43% Decrease ED Diversion Rate from 42% to FY 15-16 YTD: 53% 35% by June 30, 2016 YTD % Improvement: -24.1% 80% 70% 60% 50% 40% Ambulance Diversion Bldg 25 move Winter 15-16 Winter 16-17 Winter 17-18 Ambulance Diversion (Percent) ED Boarding correlates with diversion 75 70 65 60 55 50 45 40 R² = 0.6965 30% 20% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 MTD Target Baseline (FY 14-15) Admitted patient LOS: decision to admit to leave ED FY 15-16 Scorecard: ZSFG FY 15-16 Target: 180 True North: Care Experience Yr End % Improvement: 23.5% Year to Measure Of: Access and Flow (Means Minutes) Date Owner: Terry Dentoni & Jim Marks FY 14-15 Baseline: 235 Reduce Admit Decision Time to ED Departure FY 15-16 YTD: 357 Time for Admitted Patients from 225 minutes YTD % Improvement: -51.8% to 180 minutes by June 30, 2016 800 700 35 30 0 5 10 15 20 Number of admitted patients boarding in the ED ED Boarding of admitted patients FY17/18 Scorecard Hospital Wide Focus FY 17/18 Target: 3 True North: Year to Date QUALITY Yr End % Improvement: 73.0% Measure Of: umber of admitted patients boarding in the ED Owner: May, Marks, Dentoni, Williams FY16/17 Baseline: 11 Reduce number of boarded patients from 18.9 FY 17/18 YTD: 11.1 to 3 by June 30, 2017 YTD % Improvement: 0.1% 30.0 25.0 600 500 400 300 200 100 0 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 MTD Target Baseline (FY 14-15) 20.0 15.0 10.0 5.0 18.0 19.0 13.4 Zuckerberg San Francisco 0.0 General 12.6 10.6 11.7 10.0 4.1 10.0 6.9 7.3 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May ED MTD TOTAL MTD Target Baseline 9.4 11.2 7.7 10.4 8.9 10 4.4

2017 LESSONS LEARNED: ED volume is exceeding ED capacity at current LOS ED patients registered and seen: FY14/15 - FY17-18 ED daily volume 250 240 230 220 210 200 190 Winter 14-15 Chart Title Winter 15-16 Winter 16-17 Winter 17-18 ED needed 7A-7P by month FY14/15-FY17-18 ED needed 90 80 70 60 50 40 30 20 Maximum ED Bed Number Winter 15-16 Chart Title Winter 16-17 Winter 17-18 With H58 closed With H58 open 180 10 170 160 150 2014/07 2014/09 2014/11 2015/01 2015/03 2015/05 2015/07 2015/09 2015/11 2016/01 2016/03 2016/05 2016/07 2016/09 2016/11 2017/01 Normalized Linear (Normalized) Linear () 2017/03 2017/05 2017/07 2017/09 2017/11 2018/01 2018/03 0 2015/07 2015/08 2015/09 2015/10 2015/11 2015/12 2016/01 2016/02 2016/03 2016/04 2016/05 2016/06 2016/07 2016/08 2016/09 2016/10 2016/11 2016/12 2017/01 2017/02 2017/03 2017/04 2017/05 2017/06 2017/07 2017/08 2017/09 2017/10 2017/11 2017/12 2018/01 2018/02 2018/03 Series1 Series2 LOS of patients discharged from the ED FY 15-16 Scorecard: ZSFG FY 15-16 Target: 250 True North: Care Experience Yr End % Improvement: 10.1% Year to Date Measure Of: Access and Flow (Means Minutes) Owner: TD & JM FY 14-15 Baseline: 278 Reduce ED Arrival to Departure Time for FY 15-16 YTD: 252 Discharged Patients from 244 minutes to 210 YTD % Improvement: 9.4% minutes by June 30, 2016 300 280 260 240 220 200 180 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar Apr May MTD Target Baseline (FY 14-15) 11

2017 LESSONS LEARNED: Our flow model predicts next winter volume and current LOS will create an ED capacity criticality Model of next years ED needs* 100 Chart Title Winter 17-18 Winter 2019 90 80 Winter 16-17 We are here 70 ED Beds Needed 60 50 40 30 Winter 15-16 20 10 0 2015/07 2015/09 2015/11 2016/01 2016/03 2016/05 2016/07 2016/09 2016/11 2017/01 2017/03 2017/05 2017/07 2017/09 2017/11 2018/01 2018/03 * Volume increases 8%/yr; use prior years mean LOS 2018/05 2018/07 2018/09 2018/11 2019/01 2019/03 12

2018 STRATEGIES 8 3 A d v a n c i n g E q u i t y I m p r o v i n g Va l u e a n d P a t i e n t O u t c o m e s E n s u r i n g F l o w a n d A c c e s s O p t i m i z i n g C a r e E x p e r i e n c e O p t i m i z i n g W o r k f o r c e C a r e & D e v e l o p m e n t T h e Z S F G Wa y B u i l d i n g f o r t h e F u t u r e I m p l e m e n t i n g a n e n t e r p r i s e - w i d e E l e c t r o n i c H e a l t h R e c o r d The ZSFG Way A d v a n c i n g E q u i t y I m p r o v i n g Va l u e a n d P a t i e n t O u t c o m e s E n s u r i n g F l o w a n d A c c e s s O p t i m i z i n g C a r e E x p e r i e n ce F i n a n ci a l S t e w a r d s h i p Building for the Future Implementing an enterprise-wide Electronic Health Record 13

Align Vertically Moving the Flow Strategy to the Operational Level True North Metric(s) (Organization wide goals) True North Metric Access and Flow Tactical A3 s (Organization wide plan) Optimize Patient Flow A3 Operational A3 s (Front line problem solving) Multiple (4) driver metrics 4 Target metrics: e.g. Reduce ED LOS Reduce ED LOS Reduce LLOC Low Acuity Pts to UCC Develop CDU Unit/workshop A3 s ED Fastrack Triage Improve horizontally at the unit level

Monitoring Progress/Driving Improvement Weekly Exec Flow Mtg with Operational A3 owners

Countermeasures and Next Steps Root Cause Countermeasure Owner Date Increased ED volume 1. Complete analysis of sources of ED volume increase 2. Engage relevant stakeholders for focused CMs (PC, ED to UCC) 1. Marks/To 2.Marks/May/SFHN May 2018 - ongoing Increased LLOC days 1. LLOC placement team work 2. Roll out DMS in CC 3. Capacity and Reduce Social Admits A3/PDSA 1.May/Dentoni/Hirose/ Hiramoto 2. KPO 3.Ortiz/Chase/Kanzaria March 2017- present Increased discharge ED LOS 1. Continue Care-Start PDSA 2. Review and prioritize RN and Provider staffing to cover CS and FT 1. Navarro/Singh 2. Navarro/Colwell/Willia ms/ Marks April 2018- ongoing 16