PUTTING THE PATIENT FIRST IN PATIENT PLACEMENT 8 Hospital System, 1 Freestanding ED Provide healthcare to 26 surrounding counties within South Texas International Transfer Services Methodist Healthcare is the most preferred provider in healthcare services for San Antonio* JC Primary Stroke Center Chest Pain Accredited Transplant Program-Heart, Kidney, Liver Hear Transplant Program serving San Antonio area for 25 years Obstetrics approximately 10,000 deliveries per year Specialty Transport Teams South Texas Tele-Stroke Network 2
History and Background: ~600 hours of diversion per month (2007 data) Average time to place- 7 hrs ED Hold hours increasing Increasing LPMSE No data/manual data Home grown electronic request system Hidden/Batched beds Communication silos Isolation needs not communicated Real-Time needs not available Creation of Patient Management Center: Very tight timeline Engaged with TeleTracking patient flow consulting team Six week engagement, assisting with protocol development, algorithms, education, process changes TeleTracking TransferCenter application implementation Partnering with TeleTracking consulting attributed to our on-time, successful implementation.
What is the Patient Management Center? One-Stop Centralized Patient Placement Center Transfer Center Tele-Stroke Centralized Hub that acts as Air Traffic Control View of enterprise-wide 1,800 bed Manages Patient Flow Initiative Data analysis for performance improvement (system-wide Throughput Initiative) Building our Foundation- A Critical First Step TeleTracking Capacity Management Suite System State-of-the-art bed management software Real-time view of bed status and bed availability Real-time bed requests Eliminated manual processes Monitors housekeeping turn times Brings visibility to pending and confirmed discharges Allows for indication of patient attributes & bed attributes Provides the data needed to drive behavior
All RN staff specializing in Critical Care, Emergency Medicine, Telemetry and OR Patient Placement with authority! Manages and assigns beds for all admissions Coordinates~8500 patient movements a month Only staff allowed to block beds Hard stops for assigning beds Created 10 minute rule All phone lines recorded Implemented Processes enterprise wide; Census pages, Code ICU, Blocked Beds, OR/Cath Lab notification, Bed Ahead process, Unit Capacity
Patient Attributes
Centralized Transfer Center A ONE Call Solution Located within the Patient Management Center Dedicated Transfer RN, includes securing accepting physician Manages and accepts all transfers into MHS- always yes Streamlined processes by specialty Air Transport Assistance to include auto launch Processes in place for direct flow to Cath Lab Utilizes TeleTracking TransferCenter application 100% transfer review Monthly Metric Dashboard
Transfer Center Metrics Dashboard Accepted/Declined/Cancelled/Consults Time of Transfer request to Acceptance Time of Day Day of Week Breakdown by Specialty Origin Unit of Incoming Patients Payor Status (by Specialty) Surgical Procedure Transport Mode Accepting Physicians Physician/Facility Survey Transfer Center Scorecard
Methodist Health System Patient Population Rural Community Hospitals Referring Physicians Transfer Center Physician Offices Referring Physicians
Adult Transfers (October 2009 to December 2012) Series3 Methodist Healthcare Patient Management Center www.sahealth.com/pps Patient Placement Metrics and Reporting Tools
50 Daily Calls Offered by Hour of Day 48 Totals: Offered: 561 45 40 35 33 38 35 34 37 40 36 34 35 30 25 20 18 24 19 21 25 Calls Offerred 15 14 15 10 8 6 7 8 9 7 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Total Monthly Placements (including PreAdmits and in-house Transfers) 12000 T o t a l M o n t h l y 10000 8000 6000 6820 6690 6443 10055 9804 9755 95729509 9341 9033 9119 8655865186398610 8731 8368 8240 8366 7965 8097 81998262 7802 7766 77587739 7807 7605 7348 7397 7470 7598 P l a c e m e n t s 4000 2000 0
Patient Flow Initiative Facility Gridlock Delayed Discharges on M/S units Tele and ICU at capacity, patients can not move to floor Approaching Critical Census, ED/PACU full New patients cannot be admitted, ED on silent divert, transfers declined, OR cases canceled
Impact on MHS Service and Quality - Delayed care to our patients Financials and Growth - Lost Business and impacts our bottom line People - Physician, employee and patient and family dissatisfied TeleTracking Consulting Engagement: Visited all facilities Interviewed key personnel Observed processes in action and provided flow charts Assessment & gap analysis Make recommendations for patient flow improvement Culture change
Priorities Break down silos EVS, Case Management, Transport, ED OR, Physician Participation Metrics Key metrics, Daily reports, Weekly CEO Dashboard
Metric ED Hold Hours Request to Assign Time Pull-time (assigned to occupied) Definition ER Holding Hours report Time from bed request to PPC assigns bed Clean bed to patient occupy Total Time to Place Total time bed request to Patient EVS DC TAT Total time from dirty request to clean Avoidable Days Accumulation of delays in service D/C delays Needs further definition Discharge before 11am % of patients physically leaving bed prior to 11am # of patients with hospital Pt stay > 7 days inpatient stays longer than 7 days # of patients with hospital Pt stay > 50 days inpatient stays longer than 50 days Daily Report Card Need further clarification Key Metrics Metric D/C Order to Patient Discharge Dead bed time Diversion Hours LPMSE Observation Patients > 24 hours Outpatients in Beds ED admissions as % of Total Admissions One Day Stays Definition Input of physician DC order to patient leaving (manual input) time bed is vacated prior to notification of EV # of hours spent diverting ambulances Left Prior to Medical Screening Exam # of observation patients staying longer than 24 hours Number of outpatients in beds Percentage of ED admits vs. Total admits to the hospital # per month Total Hospital Average Occupancy Rate of Occupancy Rate hospital ICU Occupancy Rate Average Occupancy Percentage of ICU Methodist Healthcare Patient Management Center www.sahealth.com/pps Methodist Healthcare System Throughput Metrics and Reports
# o f P a t i e n t s 40 35 30 25 20 15 10 5 0 10 3 11 9 8 7 2 2 2 Patient Discharge Volume and Request for Placement MHS (Hour of Day) Only 11% of patients are being DC d by 11am and 25% of patients are DC d by 1pm 7 10 1 2 1 1 15 15 3 22 6 26 14 28 28 23 23 26 30 28 37 37 28 26 33 23 26 21 32 18 18 17 13 14 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Requests by HOD Hour of Day DC Volume by HOD The bulk of Discharges (50%) are occurring between 3-7pm, and patients are being placed at the same time. 9 Before 7 13 5 40.0 35.0 With the new design, 25% of patients would be DC d by 11am and 50% by 1pm. Proposed DC Volume and Count of Placements (with 25% of Patients DC'd by 11am) 32.1 36.5 36.6 33.0 30.0 25.0 27.9 28.2 28.3 27.5 26.4 26.1 26.4 25.8 25.5 24.6 23.3 22.4 21.4 20.0 15.0 17.9 16.2 14.9 14.6 13.8 17.6 16.5 14.4 14.4 12.9 Placements by HOD DC Volume by HOD 10.0 10.2 10.9 9.2 10.2 10.0 8.9 5.0 0.0 7.5 7.1 6.6 6.5 5.6 5.4 5.3 5.0 4.9 3.4 2.2 2.0 1.9 1.4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 After Early Discharges helps to eliminate the in-patient process of admissions and discharges occurring simultaneously
Daily Placement Throughput Performance Report for Previous Day - Metro Campus (Emergency Department Admissions) Occupied Unit # of Average Request Placements To Assign Minutes Average Request To RTM Minutes Average RTM To Assign Minutes Average Pull Average RTM To Time (Transport) Occupy Minutes Within 60 Minutes 7TH FL TELE 13 22.26 20.27 13.37 65.07 74.62 30.77% CVTS 4 8.66 18.18 3.66 72.33 62.80 0.00% GEN SURG 1 6.65 0.10 6.55 76.43 82.98 0.00% IICU 2 36.77 0.10 5.08 75.46 64.82 0.00% MEDICAL / 4 3.08 3.47 3.14 50.31 71.43 25.00% RENAL MICU 1 0.70 0.00 0.70 105.88 106.58 0.00% POST PARTUM /GYN NORTH 1 59.08 60.45 98.83 97.47 0.00% Total 26 18.32 16.43 8.76 68.02 74.36 19.23% Daily Discharge Compliance Performance Report (Previous Day) - Metro Campus Home Unit Pending Discharge Compliance Confirmed Discharge % of Discharges % of Discharges Number of Compliance Percentageby 11AM by 1PM Discharges 7TH FL TELE 100.00% 100.00% 0.00% 12.50% 8 CVTS 100.00% 100.00% 0.00% 66.67% 3 GEN SURG 100.00% 100.00% 12.50% 25.00% 8 IICU 75.00% 50.00% 25.00% 50.00% 4 MEDICAL / RENAL 100.00% 100.00% 0.00% 0.00% 6 ONCOLOGY 100.00% 100.00% 0.00% 0.00% 2 ORTHO/ NEURO 100.00% 100.00% 0.00% 50.00% 2 Total 96.97% 93.94% 6.06% 24.24% 33
RTM Process (Ready-to-Move) Implemented in August 2011, this process is designed for precise patient placement from the ED to inpatient units. ED requests an inpatient bed in TeleTracking system. PPC targets patient to requested unit from the ED RTM timer is hit in TeleTracking, which notifies PPC that patient is now clinically Ready to Move Patient is then assigned a bed to the targeted unit and is ready to be transported. Our Patient Flow Success: Deemed a HCA best practice for centralized patient management ED diversions dropped from 700 hours to just eight hours Transfer Center volume more than tripled Digital bird s eye view of system-wide capacity helped reduce ED hold hours by 50% System-wide bed searches completed within 10 minutes Transfer Acceptance Rate of 99.6%
Clinical Success: Door to Balloon (Rural Transfer) -120 min Better compliance with Core Measures Received the Community Board award for outreach to patients Positive feedback from MHS physicians Positive feedback from transferring facilities Decrease in risk exposure related to EMTALA Next Steps Integrating TeleTracking with more care support systems (e.g. facilities scheduler) Integration of Patient Status Center into Patient Management Operations Utilization of discharge planning milestones across the enterprise Working with TeleTracking to maximize utilization and throughput in the OR Automating patient and staff location using TeleTracking Real-Time Locating System technology
TeleTracking Real-Time Patient Flow Dashboards TeleTracking Real-Time Patient Flow Enterprise Dashboard REAL-TIME CENSUS VS. CAPACITY INPATIENT CENSUS BY CAMPUS ED PATIENTS CURRENTLY WAITING CONFIRMED DISCHARGES BY UNIT
TeleTracking Real-Time Patient Flow Unit Dashboard CENSUS & CAPACITY BY UNIT ED PULL TIME PACU PULL TIME PENDING AND CONFIRMED DISCHARGES BY UNIT TeleTracking ED Dashboard MEASURES PULL TIME FOR ALL MAJOR MILESTONES INCLUDING BED OR BAY PLACEMENT, MD VISIT, DECISION TO ADMIT & TRANSPORT/ED DEPARTURE
TeleTracking Transfer Center Dashboard PHYSICIAN RESPONSE TIME OVERALL RESPONSE TIME DAILY CASE BREAKDOWN CASES BY SERVICE LINE CASES BY REFERRING FACILITY Must Haves: CEO support- top down Dedicated bed coordinators who are empowered to operate autonomously Centralized process Technology to optimize efficiency Data analyst dedicated to providing real time data to drive behavior changes Culture change- inpatient staff no longer manage the beds Accountability
Lessons Learned: Communicate, communicate, communicate Define expectations No tolerance for not using system Implement hard stops on initiation Culture change- old habits must die Transparency of metrics Q & A Susan Sewell RN, VP Patient Management Susan.Sewell@mhshealth.com