Why Do Flow? The Cincinnati Children s Hospital Journey. December 11, PDF Free Download

December 11, 2017 Why Do Flow? The Cincinnati Children s Hospital Journey Frederick C. Ryckman, MD Professor of Surgery / Transplantation - Retired Sr. Vice President Medical Operations Cincinnati Children s Hospital University of Cincinnati fcryckman1@gmail.com Nothing to Disclose

Nothing to Disclose 2 I have no relevant financial or nonfinancial relationship(s) within the services described, reviewed, evaluated or compared in this presentation.

Cincinnati Children s Hospital 550 Bed Medical Center Admissions/Year 30,848 Outpatient Visits 1.02 M Surgical Procedures 32,000 cases 20 OR s, 2 IR suites, Hybrid Cath 8 OR Outpatient Surgery Center 1.4 M sq. ft. Research Space 15,000 Employees

Who am I 40 years clinical practice Pediatric Surgery : Transplantation : ECMO Surgical Director Transplantation : ECMO Multi-Disciplinary Teams Evidence Based Care Sr. Vice President Medical Operations Interim COO Peri-Operative Services Director Operational Leader Flow and Capacity Clinical Director Pediatric Surgery, ACGME Fellowship

What Do Patients Hire Us to Provide What do they call Value Make the Right Diagnosis Deliver the Correct Therapy / Treatment Outcomes Prevent Complications or Errors in Care Deliver Safe Care regardless of the Inherent Risks Safety Get Me Home, Keep me at Home Respect my needs Patient / Family Experience Give me my Money s Worth Value This is all FLOW management it is essential for SAFETY, PATIENT / FAMILY EXPERIENCE and QUALITY DELIVERY

Flow is a Safety Initiative Getting the Rights Right Right Diagnosis and Treatment Right Patient in Right Bed Location Right Nursing Staff and Staffing Expertise Disease Specific Expertise Equipment Expertise Best Care Model Requires ability to Predict future needs, and manage present capacity and control variability Operations Management techniques to understand and manage variability are the key to success

Value Equation for Healthcare Value = (Outcomes + Patient Experience) x Appropriateness Cost + Hassle Factor

Aims of Flow Linkage to safety Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit Chalfin DB, Trzeciak S, Likourezos A et al. Critical Care Medicine 2007;35:1477-83. 50,322 patients delayed > 6 hours (1,036) vs no delay < 6 hours (49,286) Primary Outcome Mortality ICU Mortality 10.7% delayed vs 8.4% no delay p<0.01 In-hospital Mortality 17.4% delayed vs. 12.9% no delay - p<0.001 Secondary Outcome Hospital Length of Stay 7 days delayed vs. 6 days no delay p<0.001 Conclusion Delay in ICU transfer led to increased Mortality and LOS

Aims of Flow Linkage to safety Association of delay of urgent or emergency surgery with mortality and use of health care resources McIsaac DI, Abdulla K, Yang H et al. CMAJ 2017;189:E905-912. 15,160 non cardiac surgery patients Delay booking to OR entry > institutional accepted wait times 5 levels 2,820 patients (18.6%) experienced a delay Results: Mortality 4.9% delayed vs 3.2% no delay OR=1.59 Propensity Matched Mortality OR 1.56 Increased LOS (2.6days) and Cost ($3,335) as well

CBDI: Patient Flow and Safety 56 beds in CBDI 6/13 68 beds in CBDI 2/14 80 beds in CBDI 4/14 360 new oncology patients per year 100-110 bone marrow transplants per year

CBDI: Patient Inflow and Safety 4

Primary BSI Rate per 1000 line days July_11 (n=1247) Aug_11 (n=1094) Sept_11 (n=1122) Oct_11 (n=1238) Nov_11 (n=1295) Dec_11 (n=1380) Jan_12 (n=1526) Feb_12 (n=1362) Mar_12 (n=1434) Apr_12 (n=1550) May_12 (n=1352) Jun_12 (n=1410) Jul_12 (n=1501) Aug_12 (n=1415) Sep_12 (n=1240) Oct_12 (n=1280) Nov_12 (n=1058) Dec_12 (n=1136) Jan_13 (n=1228) Feb_13 (n=1081) Mar_13 (n=1234) Apr_13 (n=1314) May_13 (n=1368) June_13 (n=1246) Jul_13 (n=1695) Aug_13 (n=1652) Sep_13 (n=1456) Oct_13 (n=1606) Nov_13 (n=1473) Dec_13 (n=1414) Jan_14 (n=1553) Feb_14 (n=1426) Mar_14 (n=1774) Apr_14 (n=2157) May_14 (n=2222) CBDI: Unit Stress and CA-BSI 4.0 Primary BSI Rate in CCHMC CBDI (July 2011-May 2014) 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Month Monthly Primary BSI Rate Median BSI rate Control Limits

Staffing and Environment - Mortality Nurse Staffing and Hospital Mortality Tertiary Medical Center 197,691 patients, 176,696 RN shifts, 43 hospital units Relationship between nurse staffing and patient turnover Risk of Death 2-3 % for each below target shift Risk of Death 4-7 % for every high turnover shift Admissions, discharges, and transfers Risk of Death 12 % for each below target shift Risk of Death 15 % for every high turnover shift Independent Variables when considering risks Needleman J. et al. N Engl J Med 2011;364:1037-45. ICU Patient Non-ICU Patient 1 st 5 days LOS

Critical Care Nursing and Outcomes Two Studies Characteristics of Critical Care Nursing and Pediatric Cardiac Surgery Mortality 2009-10 38 Children s Hospitals Risk Adjusted 29 Children s Hospitals 15,463 patients STS Database Conclusion: Experience Matters In Hospital Mortality O.R. for each 10% change P value < 2 Years Experience 1.12 P<0.001 > 11 Years Experience 0.89 P=0.04 > 16 Years Experience 0.82 P=0.06 % RN BSN or higher 0.91 P=0.02 Hickey PA, Pasquali SK, Gaynor JW et al. Ann Thorac Surg 2016;102:1375-80. Hickey PA, Curley MA, Connor JA et al. JONA 2013;43:637-644.

Flow Failures and Flow Delays Delay Divert Wait 2 hours Go to Correct Destination Delayed Right Location Risk Treatment while delayed Right s Right Flow Delay Leave Now Go to Atlanta Maybe get to Florida Wrong Destination Need to Transfer Risk Don t Arrive Right s Wrong Flow Failure

Flow Failures and Flow Delays Flow Failure - Flow related event puts a patient in a position where they may suffer a serious safety event due to lack of resources or the correct care team Risk Very High Incorrect location to receive correct care Flow Delay Event where a patient is held in a site an inappropriate length of time, resulting in waste of their time and a delay in care progression Risk Moderate and time / site related

10/2008 2/2009 6/2009 10/2009 2/2010 6/2010 10/2010 2/2011 6/2011 10/2011 2/2012 6/2012 10/2012 2/2013 6/2013 10/2013 2/2014 6/2014 10/2014 2/2015 6/2015 10/2015 2/2016 6/2016 10/2016 02/2017 # of New Patient Failures Total # of Bed Days Critical Flow Failure System Wide Function Monthly Critical Flow Failures 450 500 400 450 350 400 300 350 250 300 250 200 200 150 150 100 100 50 50 0 0 Flow System Failure Holds in the ED Patients staying overnight in the PACU Delay Failures Times PICU bed not immediately available for Urgent Use Delayed or canceled surgery because of bed capacity Patients who remain in an ICU bed longer than medically necessary because an appropriate bed is not available Placement Failures Psychiatry patients placed anywhere outside of their primary unit Hem/Onc/BMT patients placed anywhere outside of their primary unit Transplant patients not on A4N Ventilated patients who are admitted to the ICU because a bed is not available on TCC Month # of New Failures TOTAL CRITICAL FLOW FAILURES 5 N Last Update: 2/2/2015 by Michael Ponti-Zins, James M. Anderson Center for Health Systems Type of Control Chart: P Chart

System Wide Patient Flow Delay Measure Composite Measure Delay Definition PACU > 20 Min ICU to floor > 2 Hr ER to Adm > 1 Hr

System Level Measures Health Care Delivery System Transformation Strategic Improvement Priorities and System Level Measures ACCESS FLOW PATIENT SAFETY CLINICAL EXCELLENCE REDUCE HASSLES TEAM WELLBEING FAMILY CENTERED CARE 3 rd Next available appointment Flow Failures Patient Delays Discharge Prediction and Execution Growth Prediction Resource Prediction Adverse drug events (ADE) per 1,000 doses Nosocomial infection rates: Bloodstream infection rate Surgical site infection rate infection rates: VAP Safe Practices Serious Safety Events Codes outside the ICU rate/1000 days Standardized PICU Mortality Ratio Expected/ Actual % use of Evidence- Based Care for eligible patients Functional Health Status Status Touch Time for Providers Employee Satisfaction Staffing Effectiveness Staff Physician Satisfaction Voluntary staff turnover rate Accident rate for staff with Work days lost Overall Rating: Patient Experience Risk Adjusted Cost per Discharge

Organizing For Transformation 20 Board Oversight Senior Leadership Focus System-Wide Priorities Operational Excellence Teams Division/Microsystem-Based Priorities Individual System Performance Data Board Chair We Own Safety (Flow) Ownership of Mission Goals and Integration of Safety : Flow Front-Line Leaders Leading Skilled Experienced Leaders MD:RN Diad + Assoc. Leads Always On-Stage Focus on Process Execution Feedback on Process and Outcome Success

Leadership Design O.R. Smoothing Project LEADERSHIP GROUP CEO / CFO Active Support MD Surgery:Anesthesia / RN Nursing Director ROLE - LEAD WORKING GROUP Multi Disciplinary Surgical / Proceduralists Nursing Anesthesia Administration - Data Support / Quality Improvement Teams ROLE SET PRIORITIES IMPLEMENT - MONITOR PERFORMANCE Case Stratification Clinically Established Urgency Based Time Goals Patient Access Determined by Clinical Need Clinical Criteria Optimize Access - Maximum Patient Safety

Hospital Flow - Challenge of Team Multiple Sites All Interactive / Interdependent Families Nursing E D Medical Staff Patients Housestaff O R Out Patients I C U In Patients

IHI Theory on Flow Outcomes Primary Drivers Secondary Drivers Specific Change Ideas Decrease overutilization of hospital services Shape or Reduce Demand Relocate care in ICUs in accordance with patients EOL wishes Relocate care in Med/Surg Units to community-based care settings Relocate low-acuity care in EDs to community-based care settings Decrease demand for hospital beds through delivering appropriate care Decrease demand for hospital beds by reducing hospital acquired conditions 1. Proactive advanced illness planning 2. Development of palliative care programs (hospital-based and community-based) 3. Reduce readmissions for high risk populations 4. Extended hours in primary care practices 5. Urgent Care and Retail Clinics 6. Enroll patients in community-based mental health services 7. Paramedics & EMTs triaging & treating patients at home 8. Greater use of clinical pathways and evidence-based medicine 9. Care management for vulnerable/high risk patient populations 10. Decrease complications/harm (HAPU, CAUTI, SSI, falls with harm) and subsequent LOS 11. Redesign surgical schedules to create an predictable flow of patients to downstream ICUs and inpatient units Optimize patient placement to insure the right care, in the right place, at the right time Increase clinician and staff satisfaction Demonstrate a ROI for the systems moving to bundled payment arrangements Match Capacity and Demand Redesign the System Decrease variation in surgical scheduling Oversight system for hospital-wide operations to optimize patient flow Real-time demand and capacity management processes Flex capacity to meet hourly, daily and seasonal variations in demand Early recognition for high census and surge planning Improve efficiencies and throughput in the OR, ED, ICUs and Med/Surg Units Service Line Optimization (frail elders, SNF residents, stroke patients, etc.) Reducing unnecessary variations in care and managing LOS outliers 1. Assess seasonal variations and changes in demand patterns and proactively plan for variations 2. Daily flow planning huddles (improve predictions to synchronize admissions, discharges and discharges) 3. Real-time demand and capacity problem-solving (managing constraints and bottlenecks) 4. Planning capacity to meet predicted demand patterns 5. High census protocols to expedite admissions from the ED and manage surgical schedules. 1. Redesign surgical schedules to improve throughput and to improve smooth flow of patients to downstream ICUs and inpatient units 2. Separate scheduled and unscheduled flows in the OR 3. ED efficiency changes to decrease LOS 4. Decrease LOS in ICUs (timely consults, tests and procedures) 5. Decrease LOS on Med/Surg Units (case management for patients with complex medical and social needs) 6. Advance planning for transfers to community-based care settings 7. Cooperative agreements with rehab facilities, SNFs and nursing homes

Working Premise Surgical Care 24 No patient wants compromises in their care if they are the one having surgery elective or emergent Surgeons want to deliver great, careful and safe care for their patients We regularly structure care in the OR around efficient and revenue enhancing scheduling of elective cases and block time Delayed urgent case scheduling leads to increased risk of complications and poor outcome

Surgical Streams of Care Urgent / Emergent Surgery Predictable and Measurable Natural Variation Possible to Model Can be managed within the System with resource allocation Delay Increased risk and worse outcomes Elective Surgery Unpredictable Whim of Surgical Schedule High variability over time Delay Case specific risk Initial Design around Urgent Needs Goal No urgent cases in Block Time Allocate Block for Urgent Needs

Traditional Block Reactive System Urgent Emergent Cases placed within Block Time as needed Elective Case Plan disrupted, prolonged waiting time for elective patients Inefficient (Unsafe) Access for Urgent Cases Push complex Elective Cases into the late hours Overtime Wrong Team in OR Not Ideal

Scheduling Guidelines A to E Acute Life and Death Emergencies A < 30 Minutes Airway emergency(upper airway obstruction) Cardiac surgery postop bleeding with tamponade Cardiorespiratory decompensation (severe) Liver transplant postoperative emergency Malrotation with volvulus Massive bleeding Mediastinal injury Multiple Trauma-unstable or O.R. resuscitation Neurosurgical condition w/imminent herniation Emergent, but not immediately life threatening B < 2 Hours Acute shunt malfunction Acute spinal cord compression Bladder rupture Bowel perforation, traumatic Cardiac congenital emergencies w/hemodynamic or pulmonary instabilities Compartment syndrome Donor harvest ECMO cannulation Ectopic pregnancy Embolization for acute hemorrhage Esophageal atresia with tracheoesophageal fistula Gastroschisis/omphalocele Heart, heart/lung, lung, liver and intestinal transplants Incarcerated hernias Intestinal obstruction with suspected vascular compromise Intussusception-irreducible Ischemic limb/cold extremity (compromised arterial flow) Liver/Multivisceral/SI Transplant (when organ available) Liver transplant with suspected thrombosis Newborn bowel obstruction Open globe Orbital abscess Pacemaker insertion for complete heart block Replant fingers Replant hand or arm Spontaneous abortion GUIDELINES FOR SURGICAL CASE GROUPING DIAGNOSES/PROCEDURES (guideline only: medical judgment required) Urgent C < 4 Hours Abscess with sepsis Airway (non-urgent diagnostic L&B, flex bronch, non-symptomatic foreign body) Appendicitis-with sepsis/rapid progression Biliary obstruction non-drainable Cardiac ventricular assist device placement Cerebral angiogram for intracranial hemorrhage Chest tube placement in patient w/unstable vital signs, increased work of breathing and decreased O2 saturation Contaminated Wounds-Multiple Trauma Diagnostic/therapeutic airway intervention Hepatic angiogram w/suspected vascular thrombus Hip Dislocation Intestinal Obstruction-no suspected vascular compromise Kidney transplant (ORGAN AVAILABLE) Liver laparotomy Massive soft tissue injury Nephrostomy tube placement in patient w/sepsis Obstructed kidney (stones) with sepsis Older child with bowel obstruction PICC placement where patient has no access but needs fluids/medications urgently Progressive shunt malfunction Traumatic dislocation-hip Unstable neurosurgical condition Semi-Urgent D < 8 Hours Abscess drainage Appendicitis-stable/elective Caustic ingestion Chest tube in patient w/stable vital signs Chronic airway foreign bodies Closure abdomen-liver transplant Coarctation repair in newborn Esophageal foreign body without airway symptoms GJ tube/nj tube placement with no other nutrition access Hematuria with clot retention I & D abscess without septicemia Joint aspiration or bone biopsy prior to starting antibiotic therapy Kidney transplant (ORGAN NOT YET AVAILABLE) Liver/Multivisceral/SI Transplant (ORGAN NOT YET AVAILABLE) Add-on case to elective schedule E < 24 Hours Needs to be done that day, but does not require the manipulation of the elective schedule, pyloromyotomy Broviac Closed reduction Eyelid/canalicular lacerations Facial nerve decompression Femoral neck fracture Liver biopsy Mastoidectomy Open fracture grade I/II Open reduction of fracture PICC placement-has other IV access Retinopathy of prematurity treatment Unstable slipped capital femoral epiphysis

Block with Urgent Access Assured Predictive system Urgent Cases in Defined Rooms with Scheduled Teams Resources needed can be modeled Care based on Urgency / Medical Need

Jul 2006 (n=278) Sep 2006 (n=290) Nov 2006 (n=239) Jan 2007 (n=217) Mar 2007 (n=263) May 2007 (n=262) Jul 2007 (n=285) Sep 2007 (n=282) Nov 2007 (n=227) Jan 2008 (n=242) Mar 2008 (n=231) May 2008 (n=244) Jul 2008 (n=42) Sep 2008 (n=104) Nov 2008 (n=102) Jan 2009 (n=191) Mar 2009 (n=227) May 2009 (n=227) Jul 2009 (n=216) Sep 2009 (n=236) Nov 2009 (n=206) Jan 2010 (n=245) Mar 2010 (n=183) May 2010 (n=262) Jul 2010 (n=275) Sep 2010 (n=277) Nov 2010 (n=229) Jan 2011 (n=142) Mar 2011 (n=192) May 2011 (n=194) Jul 2011 (n=276) Sep 2011 (n=275) Nov 2011 (n=173) Jan 2012 (n=228) Mar 2012 (n=199) May 2012 (n=319) Jul 2012 (n=205) Sep 2012 (n=281) Nov 2012 (n=212) Jan 2013 (n=169) Mar 2013 (n=221) May 2013 (n=244) Jul 2013 (n=216) Sep 2013 (n=184) Nov 2013 (n=196) Jan 2014 (n=147) Mar 2014 (n=184) May 2014 (n=263) Jul 2014 (n=284) Sep 2014 (n=116) Nov 2014 (n=75) Jan 2015 (n=40) Mar 2015 (n=73) May 2015 (n=77) Jul 2015 (n=342) Sep 2015 (n=208) Nov 2015 (n=185) Jan 2016 (n=199) Mar 2016 (n=248) % of "B-E" Cases performed within 15% of their acceptable timeframe B-E Case Access - % Successful 100% 95% 90% 85% 80% 75% 70% 65% OR Renovation 1 Add-On Room Closed 60% Month % Cases Center Line Control Limits

Jul 2006 (n=3) Sep 2006 (n=6) Nov 2006 (n=16) Jan 2007 (n=6) Mar 2007 (n=7) May 2007 (n=6) Jul 2007 (n=7) Sep 2007 (n=3) Nov 2007 (n=1) Jan 2008 (n=3) Mar 2008 (n=3) May 2008 (n=7) Jul 2008 (n=0) Sep 2008 (n=0) Nov 2008 (n=2) Jan 2009 (n=2) Mar 2009 (n=2) May 2009 (n=4) Jul 2009 (n=2) Sep 2009 (n=5) Nov 2009 (n=1) Jan 2010 (n=2) Mar 2010 (n=0) May 2010 (n=1) Jul 2010 (n=2) Sep 2010 (n=4) Nov 2010 (n=2) Jan 2011 (n=1) Mar 2011 (n=2) May 2011 (n=1) Jul 2011 (n=0) Sep 2011 (n=0) Nov 2011 (n=3) Jan 2012 (n=2) Mar 2012 (n=2) May 2012 (n=2) Jul 2012 (n=3) Sep 2012 (n=4) Nov 2012 (n=3) Jan 2013 (n=4) Mar 2013 (n=4) May 2013 (n=1) Jul 2013 (n=2) Sep 2013 (n=3) Nov 2013 (n=2) Jan 2014 (n=3) Mar 2014 (n=3) May 2014 (n=2) Jul 2014 (n=0) Sep 2014 (n=0) Nov 2014 (n=0) Jan 2015 (n=0) Mar 2015 (n=3) May 2015 (n=1) Jul 2015 (n=6) Sep 2015 (n=7) Nov 2015 (n=0) Jan 2016 (n=1) Mar 2016 (n=5) Average Wait Time (Minutes) A Case Access Times Target 30 Minutes 270 240 210 180 150 120 90 60 30 0 Month Wait Time (Minutes) Center Line Goal Control Limits Last Updated 4/6/2016 by A. Anneken, James M. Anderson Center for Health Systems Excellence Source: CPM/EPIC

ICU Bed Availability ICU Scheduling Category Case Statistics by Category Total PICU Days Case Count ALOS Short 224.47 177 (61%) 1.27 (27%) Medium 304.74 82 (28%) 3.72 (37%) Long 302.56 31 (11%) 9.76 (36%) Grand Total 831.78 290 2.87

ICU Admission Model Elective Cases Short Stay Cases Access Cap # Cases on Schedule / Day Long Stay Cases Fixed # Beds

# of Patients with a New Failure 7/16/2008 10/14/2008 1/12/2009 4/12/2009 7/11/2009 10/9/2009 1/7/2010 4/7/2010 7/6/2010 10/4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/2011 12/28/2011 3/27/2012 6/25/2012 9/23/2012 12/22/2012 3/22/2013 6/20/2013 9/18/2013 12/17/2013 3/17/2014 6/15/2014 9/13/2014 12/12/2014 3/12/2015 6/10/2015 9/8/2015 12/7/2015 3/6/2016 6/4/2016 9/2/2016 12/1/2016 3/1/2017 5/30/2017 8/28/2017 7/16/2008 10/14/2008 1/12/2009 4/12/2009 7/11/2009 10/9/2009 1/7/2010 4/7/2010 7/6/2010 10/4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/2011 12/28/2011 3/27/2012 6/25/2012 9/23/2012 12/22/2012 3/22/2013 6/20/2013 9/18/2013 12/17/2013 3/17/2014 6/15/2014 9/13/2014 12/12/2014 3/12/2015 6/10/2015 9/8/2015 12/7/2015 3/6/2016 6/4/2016 9/2/2016 12/1/2016 3/1/2017 5/30/2017 8/28/2017 # of Patients with a New Failure 7/16/2008 10/14/2008 1/12/2009 4/12/2009 7/11/2009 10/9/2009 1/7/2010 4/7/2010 7/6/2010 10/4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/2011 12/28/2011 3/27/2012 6/25/2012 9/23/2012 12/22/2012 3/22/2013 6/20/2013 9/18/2013 12/17/2013 3/17/2014 6/15/2014 9/13/2014 12/12/2014 3/12/2015 6/10/2015 9/8/2015 12/7/2015 3/6/2016 6/4/2016 9/2/2016 12/1/2016 3/1/2017 5/30/2017 8/28/2017 7/16/2008 10/14/2008 1/12/2009 4/12/2009 7/11/2009 10/9/2009 1/7/2010 4/7/2010 7/6/2010 10/4/2010 1/2/2011 4/2/2011 7/1/2011 9/29/2011 12/28/2011 3/27/2012 6/25/2012 9/23/2012 12/22/2012 3/22/2013 6/20/2013 9/18/2013 12/17/2013 3/17/2014 6/15/2014 9/13/2014 12/12/2014 3/12/2015 6/10/2015 9/8/2015 12/7/2015 3/6/2016 6/4/2016 9/2/2016 12/1/2016 3/1/2017 5/30/2017 8/28/2017 # of Patients with a New Failure # of Patients with a New Failure Daily Critical Flow Failures 35 9 8 7 6 5 4 3 2 1 0 Delayed or Canceled Surgery Due to Bed Capacity 9 8 7 6 5 4 3 2 1 0 PICU Bed Not Available for Urgent Use Patients who Utilize an ICU bed b/c an Appropriate Bed is Not Available 9 8 7 6 5 4 3 2 1 0 12 10 8 6 4 2 0 Psychiatry Patients Placed Outside of their Primary Unit

Timeline for DC when Medically Ready Admission to Floor Discharge Criteria Set Treatment Protocol Followed Discharge Criteria Met Nurse Notifies Staff 2 Hrs Discharge Home Re-Adm & LOS Tracked Standardized Criteria Buy-In by Staff Standardized Protocols for most Tx Evaluation Criteria Modify Rounding Clear Discharge Criteria Communication Family Criteria established at admission Nurse at bedside notifies service when Medical discharge criteria are met Discharge from floor in < 2 hours Review Length of Stay and Re-Admissions as balancing measures Not about Speed Now about Efficiency

Results - DC when Medically Ready

Inter-Disciplinary Teams You may be the smartest person in the room, but You are not smarter than the collective wisdom of the room! Great team characteristics Common and shared goal, ties that permit trust and foster mutual accountability Each member brings specific and special knowledge and capabilities Physician challenge may have less knowledge than pharmacists, dietitians, social workers, respiratory therapists and nurses yet are compelled to retain decision authority Challenges Larger, highly dynamic teams further challenged in AMC s with residents, fellows, students Core team must get regular input from consultants communication challenge Patients and families are included in rounding discussions witness real-time complex problem solving may lead to anxiety and confusion

Process of Care Nurses Residents Inpatient Team Drs. and Nurses Pharmacy, Social Worker, Resp. Therapist Dietitian Family Centered Rounds Inpatient Team Family Patient Core Team Attending Pre-Rounds Held in a Private Space Rounds Held in a Patients Room Information Gathering Synthesis, Decision Making Teaching Communicate, Execute Coordinate

Analytics for Prediction of Present Bed Needs

The What if Analysis

Analytics to Forecast Growth Implications

Understanding Capacity Needs & Variability for New/Growth Programs

The Value of Analytics Bed demand predictions facilitate staffing and overflow planning right patient right team ED admit predictions improved from 40% to 70% accuracy resource allocation Encourages staff to more consistently predict and document estimated discharge date helps guide bedside care system efficiency Uncovers scheduling issues for staffing and resources right team - efficiency and access One step source to determine where there is capacity real time response

Predicting Admissions

Staffing Prediction Proactive Planning

Census Prediction Model

Census Prediction Accuracy - ICU

Census Prediction Accuracy Med Surg

Staffing Tool - AcuShift Jackie Hausfeld, RN, William Vadonish, RN, et al. CCHMC Patient Services

Microsystem Stress Report Microsystem Stress Report Week of: 1/8/2017 to 1/14/2017 Location Unit Population Capacity % Budgeted Occupancy Budgeted ADC Demand - Occupancy ADC % Occupancy To Budgeted ADC % Occupancy to Capacity Budgeted Bedside Care NHPPD Actual Average Direct Care NHPPD Variance to Direct Care NHPPD % Variance of Direct Care NHPPD Capacity - Staffing % Operational Vacancy Hours of Float Staff % Float Staff Hours Orientation % Orientatin Hours # of >13 hour Shift % 13 hour Shifts CN Assessment % Orange Shifts % Red Shifts % Orange and Red Shifts A3N Surgery 22 75.0% 16.5 15.1 91.8% 68.8% 11.6 12.0 0.4 3.5% 10.00% 81.6 10.1% 44 5.4% 0 0.0% 0.0% 0.0% 0.0% A3S TCC 24 91.7% 22.0 23.5 106.8% 97.9% 16.0 15.9-0.1-0.6% 17.97% 278.6 14.4% 425 22.0% 0 0.0% 0.0% 0.0% 0.0% A4C1 Rehab 12 69.2% 8.3 10.3 124.2% 85.9% 13.7 14.4 0.7 5.1% -0.95% 79.0 15.5% 0 0.0% 0 0.0% 0.0% 0.0% 0.0% A4N Transplant/Surgery 24 85.4% 20.5 20.8 101.4% 86.6% 13.1 12.6-0.6-4.2% 7.07% 12.1 0.9% 110 8.0% 2 1.5% 0.0% 0.0% 0.0% A4S GI/Colorectal 24 81.7% 19.6 19.3 98.4% 80.4% 11.6 15.3 3.8 32.7% 9.89% 32.9 2.8% 68 5.7% 0 0.0% 0.0% 0.0% 0.0% A5C Hem/Onc 32 90.4% 28.9 29.3 101.4% 91.7% 16.0 14.8-1.2-7.4% 9.26% 411.7 19.5% 72 3.4% 3 1.3% 0.0% 0.0% 0.0% A5S BMT 36 85.7% 30.9 20.6 66.7% 57.2% 17.5 19.9 2.5 14.3% 21.05% 76.4 4.1% 307 16.5% 2 0.9% 0.0% 0.0% 0.0% A6C Cardiology 17 88.2% 15.0 15.7 104.8% 92.4% 16.0 15.3-0.8-4.7% 11.67% 98.7 7.8% 108 8.6% 10 8.1% 0.0% 0.0% 0.0% A6N Adol. Medicine 24 72.9% 17.5 19.5 111.4% 81.3% 13.2 10.5-2.6-19.8% 9.26% 157.3 14.1% 0 0.0% 3 2.4% 7.1% 0.0% 7.1% A6S Child Medicine 24 72.9% 17.5 19.2 109.5% 79.9% 12.6 10.7-2.0-15.5% 9.73% 90.6 8.3% 0 0.0% 2 1.6% 0.0% 0.0% 0.0% A7C1 Complex Pulmonary 11 76.4% 8.4 9.5 112.8% 86.1% 12.9 13.0 0.1 1.1% 5.18% 49.4 9.3% 0 0.0% 8 11.9% 2.4% 0.0% 2.4% A7C2 CRC/Diabetes 11 81.8% 9.0 9.4 104.4% 85.5% 12.7 12.1-0.6-4.4% 14.77% 0.0 0.0% 24 5.3% 2 3.6% 0.0% 0.0% 0.0% A7NS Neurosciences 41 70.0% 28.7 32.2 112.2% 78.6% 15.1 14.0-1.1-7.1% 6.20% 224.6 11.5% 64 3.3% 2 1.0% 0.0% 2.4% 2.4% B4 NICU 59 87.8% 51.8 55.7 107.5% 94.4% 18.4 17.2-1.1-6.2% 13.55% 643.5 11.6% 326 5.9% 10 1.8% 4.8% 0.0% 4.8% B5CA Complex Airway 11 66.4% 7.3 7.0 96.5% 64.1% 15.8 17.4 1.6 10.1% -3.03% 0.0 0.0% 24 5.1% 2 3.7% 0.0% 0.0% 0.0% B5CC PICU 35 77.7% 27.2 29.2 107.4% 83.5% 26.1 24.0-2.1-8.0% 17.87% 326.9 8.2% 440 11.1% 11 2.7% 11.9% 7.1% 19.0% B6HI CICU 25 90.0% 22.5 21.6 95.9% 86.3% 25.8 23.8-2.0-7.7% 20.29% 356.4 12.2% 399 13.7% 18 6.3% 0.0% 0.0% 0.0% LA4-1 Lib CBDI 10 49.6% 5.0 2.0 41.3% 20.5% 16.2 27.1 10.9 67.2% 0.00% 0.0 0.0% 0 0.0% 0 0.0% 0.0% 0.0% 0.0% LA4-2 Lib Hosp Med 32 45.0% 14.4 16.3 113.3% 51.0% 14.1 12.7-1.4-9.7% 0.00% 0.0 0.0% 37 3.7% 3 2.7% 0.0% 0.0% 0.0% Total 474 78.3% 371.0 376.3 101.4% 79.4% 2919.7 10.0% 2448 8.0% 78 2.5% 1.4% 0.5% 1.9% Status Criteria Red Yellow Green < 90%; > 105% 90% - 95%; 100% - 105% 95% - 100% < -5% > 12% > 15% > 10 % Jackie Hausfeld, RN, William Vadonish, RN, et al. CCHMC Patient Services 16 53

NICU: Qualitative Pilot Family Stress Jackie Hausfeld, RN, William Vadonish, RN, et al. CCHMC Patient Services

Hospital Wide System for Flow and Safety 3 Times - Every Day Individual Room / Floor / System Predictions Flow, Capacity and Safety Floor Huddles PeriOp Huddle Outpt, Home, Psych ED Huddle ICU Huddles Institutional Wide Bed Huddle Flow and Capacity Management Pharmacy Pt. Transport Facilities Institutional Daily Operations Brief System Prediction Mitigation Strategy Security Housekeeping P.F.E.

Flow and Patient Placement Production Capacity, FY 2005 Maximum inpatient capacity: 425 beds ( theoretical capacity ) Barriers resulted in daily practical capacity reached at ~ 325 patients System failures: cancel surgery, deny admission Practical operational capacity was 76% of theoretical maximum capacity

Flow and Patient Placement Production Capacity, FY 2017 Inpatient capacity: 510 beds ( theoretical capacity ) Twelve years of work on: Smoothing scheduling Discharge planning Patient flow Physical layout in key bottleneck areas Re-examining patient cohorting for greater utilization Expanded practical capacity to a daily peak of 460 inpatients (90% of theoretical capacity)

What Has It Meant? Increased Safe Occupancy. (76 to 90%) Potential for 73 more inpatients/day within current bed capacity $354,000/day in potential additional net billing revenue from existing assets and staff ($129 million/year) Avoided construction of about 95 additional beds ($100+ million) beds would have been required to meet today s volume in our FY 2005 workflow system over the past 10 years living within our capacity

Summary Great management of Flow is: An essential strategy to achieve Safety An essential component of Patient Satisfaction Frees resources and time for Staff Satisfaction and Retention Increases your effective capacity to care for patients A cornerstone of your business strategy Getting the Right s Right

Thanks!

Why Do Flow? The Cincinnati Children s Hospital Journey. December 11, 2017