Section XIII Capacity Management / Throughput

Section XIII Capacity Management / Throughput Summary of Recommendations Assessment Methodology Observations of Patient Throughput Processes Common Themes Assessment and Recommendations Case Management and Nursing Ancillary Services Bed Assignment Emergency Department Implementation Plan and Methodology Patient Throughput and Capacity Management Next Steps Patient Throughput Optimization Implementation Plan Phase Phase I: Case Management/Social Work Phase I: Bed Control/Nursing Supervisors Patient Throughput Optimization Implementation Plan Phase 2 Phase II: Inpatient Nursing Phase II: Ancillary Services Patient Throughput Optimization Implementation Plan Phase 3 Phase III: Emergency Department Financial Impact Key Components for Success

Summary of Recommendations Case Management Reorganize Case Management/Utilization Review/Social Work/Pre-Auth to report to one Director. Shift current Case Management model from a UR focus to a Care Coordination focus. Determine service-specific needs for rounding practices that support discharge planning needs for patient population. Develop communication systems involving all care givers and family in coordination of patient discharge. Evaluate post-acute placement needs quickly during patient stay and communicate to the patient and family the importance of planning for the post-acute care. Implement processes during evening resident rounds to capture patients for anticipated discharge the next morning flag these patients to be discussed first during am teaching rounds, and encourage physicians to write orders during rounds. Implement clinical roadmaps for key high-volume DRGs. Collaborate with physician leadership to improve outlying LOS with physician report cards. Section XIII Page 2

Summary of Recommendations Nursing Establish Patient Throughput Steering Committee to meet on a bi-weekly basis, at a minimum, to hear reports from front-line management involved in the patient throughput initiative and to discuss roadblocks and action plans. Determine official Discharge Time most effective time should be before noon and communicate expectations to all caregivers, patients and families. Reorganize daily Bed Meeting to plan for all admissions including surgical volume, cath lab procedures that convert to inpatients, clinic patients, Emergency Department admissions, etc. Implement accountability systems to include bed management metrics on each nursing unit and with all services that support patient movement. Define and implement incentive program to identify beds quickly at the front-line staff level. Implement day before discharge notice program on all nursing units and develop accountability systems to measure use of program. Implement special flagging of lab tests, diagnostic procedures, and other support services for improved response time for patients pending discharge. Evaluate options for enhancing patient flow and proper utilization of Extended Stay Recovery Area, Observation Unit, Clinical Decision Unit and specific discharge area for post-partum patients. Section XIII Page 3

Summary of Recommendations Ancillary Laboratory Project capacity of phlebotomist draws based on current staffing and collection times. Implement special flagging of lab tests for improved response time for patients pending discharge. Document and trial a best practice phlebotomy collection run. Radiology Project capacity for each section based on current staffing and equipment. It is necessary for IT to support a special flagging of diagnostic procedures in Lab and Radiology for pre-discharged patients to improve response time for pending discharges. Analyze no-show, add-ons, cancellations, I/P, OP, ED, walk-ins and scheduled patients by day for trending. Environmental Services Implement discharge notification system in all areas to allow prioritization of patients. Assess staff understanding and compliance of the bed notification and cleaning process. Implement quality, service, and cost measurement and reporting system. Transport Negotiate with external customers on expectations of service; measure and report frequently. Develop and assign specific downtime duties. Section XIII Page 4

Summary of Recommendations Bed Assignment Define specific role for Patient Flow Coordinator to oversees all bed requests. Redefine roles and responsibilities of bed assignment team. Implement one large Bed Board to visualize all beds in the hospital simultaneously begin with a manual magnetic bed board before progressing to a more sophisticated electronic system. Implement one-call system for physicians to call for direct admission of patients into hospital. Develop process to plan for bed assignment needs using Future Scheduled Admissions information in SMS. Define and implement incentive program to identify beds quickly at the front-line staff level. Pursue opportunities to align supply and demand of beds by service. Emergency Department Engage key physician leaders in addressing the physician practice delays in the ED. Develop a strong senior management message around the sense of urgency in improving patient throughput and the role it will play in solidifying the future of UNC Hospital. Develop and implement a core set of performance metrics and targets to increase awareness and accountability around the patient throughput process. Implement an organization-wide trigger system with clear action expectations for each patient throughput process stakeholder during high census days and periods of ED overflow. Conduct a detailed analysis of ED volume trends and the feasibility of utilizing the Peds ED area as an alternate care setting to enhance patient flow. Section XIII Page 5

Assessment Methodology Assessment Financial Technical Cultural Targets Budget Long-range Plan Reports Management Tools Systems Leadership Effectiveness Communication Methods Cultural Strengths Face-to-face interviews of key stakeholders in patient throughput processes Observation of processes that impact patient throughput Data collection and analysis Section XIII Page 6

Observations of Patient Throughput Processes Nursing supervisor staffing meeting at 9:00 AM and 5:30 PM. Patient discharge processes on various nursing units. Day shift nursing report. Day shift Charge Nurse report. Health Unit Coordinator (HUC) and RN taking off patient orders (stat, d/c, routine). Request for new admission process. Multidisciplinary discharge meeting on various nursing units. Environmental services rounds. Bed assignment processes from bed request to official bed assignment. Patient Transport process for a discharged patient. Interdisciplinary rounds with various services. Emergency Department patient flow from triage through to disposition and discharge. CT and MRI patient flow and scheduling processes. Laboratory drawing processes during critical early morning hours. Inter-departmental communication methods. Section XIII Page 7

Patient Throughput is a Continuous Cycle Decision to Admit Bed Turnaround by Housekeeping Registration/ Bed Mgmt/ Authorization Financial Verification Patient Throughput Cycle Communicate to Send/Receive Areas Patient Placement to Bed Communication of Actual Discharge Actual Patient Discharge MD order to Discharge Discharge Planning Section XIII Page 8

Patient Throughput Interdependency RN/Charge RN Communication Admitting/Financial Reps EV Services Communication Social Workers RN Bed Managers Communication Physician/PA RN Case Managers Communication Ancillary Services Section XIII Page 9

Patient Throughput Structural Design Discharge Process Bed Management Process Planning Component Execution Component Turnover / Bed Cycle Assignment / Patient Placement Meaningful and measurable performance metrics Structured and streamlined communication Section XIII Page 0

Common Themes Workarounds for patient placement results in off-service patients on many units throughout the hospital, e.g., dialysis patient will be on a general medical floor. Lack of a consistent message for patient throughput, particularly as it relates to a discharge process and an official discharge time. No sense of urgency for discharging patients early in the day. Rounding practices do not support an early patient discharge. [Portions of this page are confidential and have been redacted.] Section XIII Page

Case Management and Nursing Assessment Discharge Process Planning Component Execution Component [Portions of the Assessment are confidential and have been redacted.]

University of North Carolina Hospital Discharges by Time of Day 4.00% September 20-26, 2004 2.00% 0.00% # of Discharges 8.00% 6.00% 4.00% 2.00% 0.00% 0 00 200 300 400 500 600 700 800 900 000 00 200 300 400 500 600 700 800 900 2000 200 2200 2300 Discharges Section XIII Page 3

University of North Carolina Hospital NSICU Patient Flow for Transfers Out Patient D Goal is to have a bed assigned within 5 minutes of notification and transfer a patient within hour of receiving the bed Patient C Patient B Patient A 900 00 300 500 700 900 Time from order written to bed assigned Time from bed assigned to patient moved Section XIII Page 4

University of North Carolina Hospital 3 West Cold Bed Study 3222 32072 3234 3206 3207 3233 3234 327 320 322 Ideal Goal is to d/c within 2 hours of order, respond to routine clean within 30 minutes, average room clean is 30 minutes, then move new patient in within hour of assignment 800 000 200 400 600 800 2000 2200 2400 2600 2800 3000 3200 Time from Order to D/C Time from D/C to Assigned Time from Assigned to Occupied Section XIII Page 5

University of North Carolina Hospital Sample Quality Metrics Floors Floors Floors Floors INDICATORS Area Indicator Definition Standard Frequency Environmental Environmental PACU ED Discharge within 2 hours of the order % of Discharges out by am Admission Time Transfer Turnaround Time Bed Cleaning Turnaround Time Stat Bed Cleaning Excessive Stay Excessive stay Discharges will be complete within 2 hours of the written order Comparison of the number of discharges out by AM and total discharges Admissions will be accepted to the unit within hour of notification Transfers will be complete within hour of notification Measuring the time from notification of needed cleaning to actual start of cleaning Measuring the time from notification of needed cleaning to actual start of cleaning Measuring the time from patient ready to leave PACU until actual transfer time Measuring the time from patient ready to leave ED until actual transfer out time 2 hours Daily am Daily hour Daily hour Daily 30 minutes Daily 5 minutes Daily Daily Daily Section XIII Page 6

University of North Carolina Hospital 3 West Quality Metrics 00% % of Patients D/C by am 80% 60% 40% 40.0% 20% 0% 7.7% 8.3% 0.0% 0.0% 9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004 % of Patients D/C by am Target Section XIII Page 7

University of North Carolina Hospital 3 West Quality Metrics 00% % of Patients D/C within 2 hours of Order 80% 70.0% 60% 40% 30.8% 4.7% 25.0% 50.0% 20% 0% 9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004 % of Patients D/C within 2 hours of Order Target Section XIII Page 8

University of North Carolina Hospital 3 West Quality Metrics % of Patients Transferred Out within hour 00% 00.0% 80% 60% 50.0% 40% 33.0% 20% 0% 0.0% 0.0% 9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004 % of Patients Transferred out within hour Target Section XIII Page 9

University of North Carolina Hospital 3 West Quality Metrics 00% % of Patients Transferred In / Admitted within hour 80% 60% 40% 20% 27.3% 25.0% 6.7% 45.5% 42.9% 0% 9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004 % of Patients Transferred in / Admitted within hour Target Section XIII Page 20

University of North Carolina Hospital 3 West Quality Metrics Orders by Service 25 00% 20 5 Main Admitting Services for 3 West 80% 60% 0 40% 5 20% 0 Fam Med A Med B Med E Med G Med K Med W # D/C # of Orders % of Orders by am 0% Section XIII Page 2

Case Management Recommendations Reorganize Case Management/Utilization Review/Social Work/Pre-Auth to report to one Director. Shift current Case Management model from a Utilization Review focus to a Care Coordination focus. Evaluate current role of CM in the ED and implement changed to ensure most efficient use of this resource. Identify and hire VPMA as a Physician Champion to support care coordination efforts and interface with physician groups. Determine service-specific needs for rounding practices that support discharge planning needs for patient population. Develop communication systems to involve all care givers and family in coordination of patient discharge. Evaluate post-acute placement needs as soon as possible during the patient stay and communicate to the patient and family the importance of planning for the post-acute care. Evaluate feasibility of Hospitalist program to enhance timeliness of patient care. Implement processes during evening resident rounds to capture patients for anticipated discharge the next morning flag these patients to be discussed first during AM teaching rounds, and encourage physicians to write orders during rounds. Determine best methods for daily communication to patients and families regarding anticipated day of discharge and discharge needs -begin communication on the first day of a patient s stay. Implement clinical roadmaps for key high volume DRGs. Collaborate with physician leadership to improve outlying LOS with physician report cards. Section XIII Page 22

Case Management Model All areas report to one director. Implement VPMA role to support CRM. Case Manager role. Utilize RNs as Case Managers. Divide services or geographic units based on needs. Case Manager per 25 to 30 patients. Each Case Manager would be responsible for all aspects of the patient coordination. Utilization review of all new admissions. Review every three days and as requested by payer. Utilize Interqual criteria as a basis in determining LOS. Initiate discharge planning on day of admission. Coordinate discharge needs with Social Worker. Manage cases as determined by medical condition. Appropriate placement of patients on the front-end. Dedicated Case Managers to be responsible for coding and documentation support. Social Workers continue to manage all psychosocial needs and discharge needs. Social Worker per 30 to 40 patients. Clerical support would be utilized for faxing, calling and coordinating paperwork. Transition to a Case Management Model with a Resource Center. Section XIII Page 23

Nursing Recommendations Establish Patient Throughput Steering Committee to meet on a bi-weekly basis, at a minimum, to hear reports from front-line management involved in the patient throughput initiative and to discuss roadblocks and action plans. Determine official Discharge Time most effective time should be before noon and communicate expectations to all caregivers, patients, and families. Reorganize daily Bed Meeting to plan for all admissions including surgical volume, cath lab procedures that convert to inpatients, clinic patients, Emergency Department admissions, etc. Meeting should be limited to 5 minutes. Meeting should occur each am, shortly after physician rounds. Emergency bed meetings should occur when there is the possibility of refusing admissions. Implement accountability systems to include bed management metrics on each nursing unit and with all services that support patient movement. Define and implement incentive program to identify beds quickly at the front-line staff level. Implement day before discharge notice program on all nursing units and develop accountability systems to measure use of program. Work with physicians to establish unit specific expectations. Implement special flagging of lab tests, diagnostic procedures, and other support services for improved response time for patients pending discharge. Evaluate the following options for enhancing patient flow and proper utilization of such units Extended Stay Recovery Area, Observation Unit, Clinical Decision Unit. Evaluate need for specific discharge area for post-partum patients. Section XIII Page 24

Ancillary Services Assessment Discharge Process Bed Management Process Execution Component Turnover / Bed Cycle [Portions of the Assessment are confidential and have been redacted.]

Ancillary Support Radiology 20 6 6 Days 2 8 4 0 4 6 3 3 3 CT MRI US Mammo Screening 7 3 3 3 3 Mammo Diagnostic Days to First Available Appointment Fluoro Nuc Med PET Industry Standard Section XIII Page 26

Ancillary Support Radiology MRI Days to first Available Appointment - Outpatient Days 20 6 2 8 4 2 5 5 6 5 5 4 2 7 3 8 5 5 4 2 2 2 2 9 9 6 8 Increased efficiency with outpatient scheduling may impact inpatient cases 6 9 9 8 7 0 0 9 5 6 8 4 0 '7/27 8/2 8/0 8/7 8/23 8/30 9/7 9/3 9/7 9/27 0/4 0/ Source: Scheduling Delays Report received from Radiology Inhouse MRI ACC MRI Sedations Section XIII Page 27

Ancillary Support Radiology 20 6 2 Ultrasound - Days to First Available Appointment The increase in US volume may start impacting inpatient flow due to the fact that inpatients are slotted in open areas around the outpatients 4 6 Days 8 4 3 3 8 5 5 3 8 5 4 8 0 '7/27 8/2 8/0 8/7 8/23 8/30 9/7 9/3 9/7 9/27 0/4 0/ Source: Scheduling Delays Report received from Radiology Days to First Available Appointment Section XIII Page 28

Ancillary Support Radiology Inpatient Response Time From Requisition to Start of Exam 3.5 3 3 3 3 2.5 Hours 2.5 Need to determine by nursing unit reasonable expectations to allow for optimal inpatient flow 0.5 0 CT MRI US Diagnostic Source: Interviews with Management and Area Supervisors IP Average Response Time Section XIII Page 29

Ancillary Support Lab % of patients waiting <5min from arrival time 00% 80% 60% 40% 20% 0% Outpatient Wait Times Main Hospital* Jan Feb Mar Apr May Jun Source: OP wait time received from lab Section XIII Page 30

Ancillary Support Lab Routine Test Turn Around Time % of routine tests completed by the targeted time 00% 80% 60% 40% 20% 0% Jan Feb Mar Apr May Jun Source: Result Turn Around Reports received from lab Includes all sites but excludes Urinalysis and Troponin Section XIII Page 3

Ancillary Support Lab Stat Test Turn Around Time % of stat tests completed by the targeted time 00% 80% 60% 40% 20% 0% Jan Feb Mar Apr May Jun Source: Result Turn Around Reports received from lab Includes all sites but excludes Urinalysis and Troponin Section XIII Page 32

Ancillary Support Lab % of stat tests completed by the targeted time 00% 80% 60% 40% 20% 0% Unrinalysis Urinalysis and Troponin are the only exceptions to the routines and stats meeting their targets Urinalysis is not far from the target Jan Feb Mar Apr May Jun Routine Stat Target Source: Result Turn Around Reports received from lab Section XIII Page 33

Ancillary Support Lab % of troponins completed by the targeted time 00% 80% 60% 40% 20% 0% Troponin Turn Around Time Urinalysis and Troponin are the only exceptions to the routines and stats meeting their targets Lab is aware troponin is not meeting the target and is working on resolution Jan Feb Mar Apr May Jun Day Shift Evening Shift Night Shift Target Source: Result Turn Around Reports received from lab Section XIII Page 34

Ancillary Support Environmental Services 00 Clean Beds Vs. Staffing by Time of Day 80 60 40 20 0 0 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 9 20 2 22 23 Average Rooms Cleaned Average EVS Room Cleaning Staff Total EVS Staff July 4-July 0, 2004 Section XIII Page 35

Ancillary Support Patient Transport Services Transport is reporting incomplete response time starting when the transport is assigned. What are the customer s expectations? Volume is relatively flat, why is the pending + response time rising? Transport Response Time 30 0000 25 9000 8000 Minuets 20 5 0 7000 6000 5000 4000 3000 Volume 5 2000 000 0 Jan Feb Mar Apr May Jun Jul Aug Sept 0 Pending Response Volume Section XIII Page 36

Ancillary Support Patient Transport Services The majority of delays are coded as Nursing : is this a response to time it takes from request to patient transport? Are there differences in expectations between Transport and Nursing? Transportation Services Delays Aug. 2004 Unit Patient 0.03% Transportation Delay 3.73% Equipment Delay 6.59% Wrong Info Given.99% Patient In Restroom 22.52% Nursing Delay 53.02% Doctor Delay 2.2% Average Mins. Per Delay 2. Percentage of Jobs with Delay 0.4% Total Delay Hours 7 Section XIII Page 37

Ancillary Support Operational Effectiveness - Timely Deliverable Lab Physical Therapy Radiology EVS Transport Preliminary/Final Report Evaluation/Treatment Clean Room Transport Challenges Radiology: A report generation system that does not require gaps of time in between steps (in process of implementing a voice recognition system) PT: Prioritizing patients and leaving some for the next day EVS: Bulk of discharges occur when least amount of EVS discharge staff is working Transport: Huge fluctuations in workload from minute-to-minute Positive current state, needs little improvement Neutral current state, needs some improvement Section XIII Page 38

Ancillary Support Physical Therapy Referral Response Time 60 50 48 Hours 40 30 20 0 0 24 24 Old Target New Target Actual Section XIII Page 39

Ancillary Support Proactive Management System Lab Physical Therapy Radiology EVS Transport Identified/Measured Service Indicators Target Comparison Reporting Mechanism Documented Proactive Approach to Outliers Diagnosis of Issues Using Objective Data Resolution Trials Successful Implementations Challenges Indicators that are meaningful and that drive day-to-day decision making Measuring too many or not enough indicators Challenging or realistic targets Staff understanding and buy-in to indicators Believable information (perception versus reality) Resolution trial that was ineffective what next? Positive current state, needs little improvement Neutral current state, needs some improvement Negative current state, needs much improvement Section XIII Page 40

Ancillary Support Department Culture Lab Physical Therapy Radiology EVS Transport Morale Leadership skills and implementation abilities Staff involved in issue identification and resolution Staff educated and involved in indicators measured, expectations and results Department recognizes/responds to internal and external customers needs Builds good relationships with customer departments Challenges Balancing quality, service and cost Never ending demand for faster service Differing and changing expectations from internal and external customers Managing time to include issue resolution Positive current state, needs little improvement Neutral current state, needs some improvement Negative current state, needs much improvement Section XIII Page 4

Ancillary Support Recommendations Laboratory Project capacity of phlebotomist draws based on current staffing and collection times. Implement special flagging of lab tests for improved response time for patients pending discharge. Document and trial a best practice phlebotomy collection run. Incorporate order to lab received time by area into measurements and reporting. Radiology Project capacity for each section based on current staffing and equipment. It is necessary for IT to support a special flagging of diagnostic procedures in Lab and Radiology for pre-discharged patients to improve response time for pending discharges. Analyze no-show, add-ons, cancellations, I/P, O/P, ED, walk-ins and scheduled patients by day for trending. Evaluate the need to adjust scheduling based on objective data. Add staff managed measurements relating to quality, service and budget by area. Physical Therapy Assess use/completion/follow-up of referral trigger within the patient assessment. Implement discharge notification system in all areas to allow prioritization of patients. Environmental Services Evaluate roles/responsibilities of staff and time of day for assignments. Assess staff understanding and compliance of the bed notification and cleaning process. Implement quality, service, and cost measurement and reporting system. Define stat bed clean and who should be responsible for determining a stat status. Transport Negotiate with external customers on expectations of service measure and report frequently. Develop and assign specific downtime duties. Identify a secure location for equipment storage. Section XIII Page 42

Bed Assignment Assessment Bed Management Process Turnover / Bed Cycle Assignment / Patient Placement

Bed Management Bed Assignment Advance bed planning for surgical patients Considers all possible areas for bed needs Role in moving patients Aware of potential discharges Compare potential discharges with beds needed Follow up on potential discharges Effective Bed Management Meeting Clear prioritization of patients in the bed assignment process Efficient and coordinated computer systems for bed management Efficient bed assignment process for specialty beds Nursing Supervisors Bed Assignment Challenges computer screens to be reviewed when placing a patient Lack of planning/trending of admissions from ED, Direct, Clinics, Cath Lab, other facilities Required volume vs. available volume of private rooms Need for one person to be in charge of prioritizing all patient moves (transfers, admissions, discharges) Lack of accountability system to enforce a streamlined patient throughput process Positive current state, needs little improvement Neutral current state, needs some improvement Negative current state, needs much improvement Section XIII Page 44

Bed Management Direct Admit Process Easy access for direct admits Timely registration process for direct admits upon arrival Timely bed assignment process Rapid delivery of care User-friendly direct admit process for doctors and patients Admitting Direct admit process that keeps direct admits out of the ED Challenges Long waits for bed assignments due to prioritization going to Surgery and ED, and time of discharges Lack of constant communication and coordination with clinics and patients waiting at home When a patient waits at home, they will typically go to the bottom of the priority list Providing care and a comfortable space for patients waiting for a bed assignment Inability for Physicians to order testing while patient is waiting for bed assignment Positive current state, needs little improvement Neutral current state, needs some improvement Negative current state, needs much improvement Section XIII Page 45

Bed Assignment Continuous Cycle Referrals entered in SMS Reviews multiple screens of patients waiting for bed assignments Bed Notification & Identification Process Bed assigned at any stage of the process Review Tele-Tracking Tracking for further bed assignment Review multiple screens by Floor for bed availability Section XIII Page 46

University of North Carolina Hospital Planning for Hospital Patient In-Flow Day Surgery Outpt. Procedure ER Admit Gray indicates currently planned volume. Trans. from other Hosp. Inpatient Bed Clinic Admit Red indicates other access areas where the admissions are not being planned for on a daily basis. Cath Lab Surgery Admit Direct Admit Section XIII Page 47

Bed Assignment Recommendations Define specific role for Patient Flow Coordinator to oversee all bed requests. Redefine roles and responsibilities of bed assignment team. Implement one large Bed Board to visualize all beds in the hospital simultaneously begin with a manual magnetic bed board before progressing to a more sophisticated electronic system. Evaluate need for new technology in Bed Assignment area to allow increased visibility of beds and eliminate cumbersome bed assignment processes. Implement one call system for physicians to call for direct admission of patients into hospital. Develop process to plan for bed assignment needs using Future Scheduled Admissions information in SMS. Develop and implement communication system to gather all necessary information required for proper bed assignment. Determine most effective method to determine beds that are out of service. Define and implement incentive program to identify beds quickly at the front-line staff level. Pursue opportunities to align supply and demand of beds by service. Section XIII Page 48

Emergency Department Assessment Bed Management Process Assignment / Patient Placement [Portions of the Assessment are confidential and have been redacted.]

University of North Carolina Hospital Main ED Census and IP Bed Request by Time of Day 35 June 3, 2004 C ritical patie nt flo w de lay po ints / Patie nt dis s atis fie r 3 30 25 2 Censu 20 5 Inpatient Bed Req 0 5 0 0:00 :00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 0:00 :00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 20:00 2:00 22:00 23:00 Time of Day Main ED Census Avg # of IP Bed Req 's to Bed C trl 0 Section XIII Page 50

University of North Carolina Hospital Main ED Transfers by Time of Day 4 June 2004 Average 3.5 3 Majority of transfers occur during late evening and night shift 2.5 Census 2.5 0.5 0 0:00 :00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 0:00 :00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 20:00 2:00 22:00 23:00 Time of Day Admitted Patient ED Transfers Section XIII Page 5

University of North Carolina Hospital ED Treat and Release Patient Experience Actual Patient Chart Data August 23, 2004 0:24 0:02 0:27 0:0 3:4 T&R Patient "A" 0:00 0:30 :00 :30 2:00 2:30 3:00 3:30 4:00 Check-In to Triage Triage to Reg Time Reg Time to ED Bed ED Bed to Assessment Time Assessment to Discharge Time Section XIII Page 52

University of North Carolina Hospital ED Admitted Patient Experience Actual Patient Chart Data August 23, 2004 0:4 2:59 3:54 0:36 Admitted Patient "B" 0:00 0:30 :00 :30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 ED Bed to Assessment Time Assessment Time to Bed Ctrl Request Bed Ctrl Request to Bed Assignment Bed Assignment to ED Transfer Section XIII Page 53

University of North Carolina Hospital Current vs. Potential Emergency Department LOS Current = June 2004 Average Admitted Pt LOS 4:00 2:36 This potential Admit LOS improvement equates to 0 additional hrs of ED capacity per day + This potential T & R LOS improvement equates to 6 additional hrs of ED capacity per day = 62 add'l hrs capacity or 47 add'l pts/day at target blended LOS Treat & Release LOS 3:00 :06 0:00 0:30 :00 :30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 Target LOS Current Excess LOS Section XIII Page 54

Emergency Department Recommendations Develop a strong senior management message around the sense of urgency in improving patient throughput and the role it will play in solidifying the future of UNCH. Develop and implement a core set of performance metrics and targets to increase awareness and accountability around the patient throughput process. Develop a recognition program that highlights the department/unit specific improvements made in key patient throughput performance metrics on a monthly basis. Analyze delay reason details for all ED patient intervals. Implement an organization-wide trigger system with clear action expectations for each patient throughput process stakeholder during high census days and periods of ED overflow. Conduct a detailed analysis of ED volume trends and the feasibility of utilizing the Peds ED area as an alternate care setting to enhance patient flow. [Portions of the Recommendations are confidential and have been redacted.] Section XIII Page 55

Implementation Plan Implementation Methodology ASSESS Project Blueprint Development Outline the strategic implementation plan for the project Ensure that all initiatives move the organization toward achieving the core set of improvement goals ANALYZE Detailed Operational Analysis Focus intensely on operational, financial and performance trends Initiate the implementation of the Organizational Accountability System Implement meaningful performance indicators that truly reflect the department s day-to-day operations CONFIRM Performance Reporting Matrix Design and Implementation Pilot new initiatives Install a Performance Reporting Matrix Monitor outcomes to clarify the impact and provide direction for further implementation Customize management systems and processes while focusing on leadership development COMMIT Finalize Organizational Accountability System (OAS) Set performance targets Finalize performance management tools, performance and leadership metrics Firm up streamlined, timely reporting processes Section XIII Page 56

Patient Throughput and Capacity Management Next Steps Communicate message to all staff of overall hospital patient throughput philosophy and importance of participation at all levels of the organization. Develop project goals and objectives. Initiate a project structure. Patient Throughput Steering Committee Manager/Director level biweekly update meetings Front-line staff driven workgroups Establish a data tracking system and baseline metrics. Metrics must be measurable Metrics must be timely Metrics must be meaningful Metrics must be simple Determine methods and sources for data collection. Initiate process change trials and measure success/failure based on established metrics. Communicate and provide feedback. Section XIII Page 57

Implementation PHASE I: STRUCTURAL DEVELOPMENT FOCUS AREAS Case Management Social Work Bed Control Nursing Supervisors PHASE II: DISCHARGE PROCESS OPTIMIZATION FOCUS AREAS I/P Nursing Units Environmental Services PACU (limited focus) Ancillary Services (limited focus) PHASE III: PATIENT IN-FLOW OPTIMIZATION FOCUS AREAS Emergency Department IMPLEMENTATION PLAN Weeks - 8 Weeks 9-26 Weeks 9-36 Section XIII Page 58

Patient Throughput Optimization Implementation Plan Phase Objectives Develop and implement an enhanced patient throughput management structure and accountability system. Develop and implement a multi-disciplinary Care Coordination model. Focus Areas Case Management Social Work Bed Assignment Nursing Supervisors Section XIII Page 59

Implementation Action Plan Phase I Case Management/Social Work Phase I Project Weeks CASE MANAGEMENT/SOCIAL WORK 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 Establish key performance indicators, initial performance targets and reporting process / frequency Identify performance improvement initiative leaders and focused improvement team members Set meeting structure for the project for both initiative-level work teams and senior mg progress reports Identify DRGs targeted for improvement Assess current care coordination model and discharge planning processes and the impact on patient flow Study the roles of CM, Physicians, Nursing and Support Services in the LOS management process Review Communication processes between Case Management staff and Nursing, Medical Staff, Pt/Family, Support Services & Referral Contacts Analyze clinical practice patterns and cultural issues that impact the ability to optimize LOS Review clinical pathway utilization Review opportunities to streamline the clinical documentation process Analyze managed care denials and related financial impact Assess appeal and revenue recovery processes associated with managed care denials Establish and implement care maps for specific "opportunity" DRGs identified within the top 50 Section XIII Page 60

Implementation Action Plan Phase I Bed Control/Nursing Supervisors Phase I Project Weeks BED CONTROL/NURSING SUPERVISORS 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 Establish key performance indicators, initial performance targets and reporting process / frequency Identify performance improvement initiative leaders and focused improvement team members Implement an interim bed board solution - magnetic board with all beds in service Develop and implement improvement strategies related to bed assignment process roadblocks by patient type Track and analyze bed assignment delay reasons by patient type Pursue opportunities to align supply and demand of beds by service Develop clear bed assignment guidelines by patient type Develop and implement an enhanced process that decreases the cycle time from communication of bed needs room clean bed assignment patient transfer/admission Assist in the selection and implementation process of an electronic bed board application (if necessary) Senior Management Progress Report Section XIII Page 6

Patient Throughput Optimization Implementation Plan Phase 2 Objectives Develop and implement an enhanced multi-disciplinary discharge planning and execution process. Focus Areas Inpatient nursing units, including Women and Children s (39 total units excluding Psychiatry and Rehabilitation) Environmental Services More Limited Focus PACU Ancillary Services Lab, Radiology, Physical Therapy, Cath Lab Section XIII Page 62

Implementation Action Plan Phase II Inpatient Nursing (39 Targeted Nursing Units) Phase II Project Weeks INPATIENT NURSING 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 Establish key performance indicators, initial performance targets and reporting process/frequency Identify performance improvement initiative leaders and focused improvement team members Set meeting structure for the project for both initiative-level work teams and senior mgt progress reports Analyze unit-specific patient mix and develop appropriate patient flow expectations and performance indicators Develop and implement unit-specific tools to track key patient flow and discharge indicators Develop and implement a daily day before discharge planning and communication process Establish and implement a formalized discharge process and targeted discharge time Establish a process to identify and communicate discharge needs upon admission Implement a daily review process for pending discharges, and required action Implement a special flagging of lab tests, diagnostic procedures and other ancillary services for improved response time Define and implement an incentive program to identify beds quickly at the front-line staff level Evaluate the following options for enhancing patient flow: extended stay recovery area, Observation Unit, Clinical Decision Unit, Discharge Lounge Section XIII Page 63

Implementation Action Plan Phase II Ancillary Services Phase II Project Weeks ANCILLARY SERVICES 9 0 2 3 4 5 6 7 8 9 2 0 2 2 2 2 3 2 4 2 5 2 6 Establish key performance indicators, initial performance targets and reporting process/frequency Identify performance improvement initiative leaders and focused improvement team members Set meeting structure for the project for both initiative-level work teams and senior management progress reports Evaluate roles, responsibilities of staff and assignment methodology by shift Assess staff knowledge and compliance of their role in patient throughput Align staffing levels and work load by time of day to support optimal patient flow Senior Management Progress Report Section XIII Page 64

Patient Throughput Optimization Implementation Plan Phase 3 Objectives Decrease the I/P delays from the ED. Optimize the patient throughput experience within the ED. Focus Areas Emergency Department Section XIII Page 65

Implementation Action Plan Phase III Emergency Department Phase III Project Weeks EMERGENCY DEPARTMENT 9 2 0 2 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 3 2 3 3 3 4 3 5 Establish key performance indicators, initial performance targets and reporting process/ frequency Identify performance improvement initiative leaders and focused improvement team members Set meeting structure for the project for both initiative-level work teams and senior mgt progress reports Prioritize and implement improvement strategies for delay reasons for "patient in-room disposition: patient flow Prioritize and implement improvement strategies for delay reasons for "disposition - bed assignment patient flow interval Prioritize and implement improvement strategies for delay reasons for "bed assignment - transfer" patient flow interval Develop and implement clear expectations and indicators for timely Nursing - ED communication on IP transfers Analyze current ED treatment philosophy and its impact on patient flow (compare to best practice) Perform a feasibility study on utilizing the Peds ED area as an alternative care area to enhance patient flow Senior Management Progress Report Section XIII Page 66

Financial Impact Opportunity Length of Stay Reduction ED Length of Stay Reduction Improve Observation I/P Conversion Process Decreased Variable Costs Improved Productivity Description Decrease excessive days Back-fill opportunity Decrease in elopement rate Operational Financial Impact Impact Direct Financial Benefit and Impact on ROI Decrease excessive days by 2,000 to 4,500 Additional capacity for,300 to.600 potential additional discharges to 2 additional treat and release patients per day Converting patients from Observation status to I/P when appropriate will improve revenue opportunity. Increased throughput without a change in staffing levels will decrease valuable costs per unit of service and increase productivity. $4.2 M to $5.M $5.5M to $6.6M $550,000 Indirect Financial Benefit TBD DURING IMPLEMENTATION PHASE Comments Projected opportunity represents impacting total excessive days by 50% to 60% at a savings of $350 per day. Opportunity calculation based on an estimated contribution margin/case of $4,23 per an analysis completed by Decision Support. Feasibility of back-fill opportunity will be analyzed during the implementation phase. Projected opportunity represents decreasing the elopement rate from 3.8% to 2.0%, which equates to an increase in ED charges based on the average charge per visit of $94. These financial benefits will be realized as a result of the Care Management initiatives of the Patient Throughput and Capacity Optimization Implementation Plan. Accountability systems and performance metrics implemented during the engagement teach the front-line managers how to proactively manage volume and plan for daily workload. Section XIII Page 67

Key Components for Success Recognize that patient throughput is a hospital-wide issue, not just an issue for particular departments, such as the Emergency Department and Surgical Service. Develop and communicate an overall hospital patient throughput philosophy. Communicate a message to all patient care givers that everyone is accountable for patient throughput. Establish and communicate clear, measurable indicators and outcomes. Measure the process on a continuous basis. Design and manage patient throughput as a single seamless beginning to end process. Section XIII Page 68