Emergency Department Directors Academy Phase II Spring 2018

Emergency Department Directors Academy Phase II Spring 2018 Course name: The Business Model for Patient Flow 4/30/2018, 2:00:00 PM - 2:45:00 PM, MO-03 DESCRIPTION: The patient is and always will be at the center of our efforts. In service to those patients, multiple gears are leveraged in service of those patients, including service, clinical excellence, clinical effectiveness, and flow. The presenter will discuss how these aspects combine in a business fashion, leveraging how best to deploy resources in a capacity-constrained environment, where value trumps volume. OBJECTIVES: Define and describe the principle of flow and how it adds value and eliminates waste Delineate the financial impact of applying the principles of hardwiring flow, both in the ED and hospitalwide Describe how best to leverage resources to produce the maximum results across boundaries Describe change management strategies to produce effective flow Discuss the impack of these strategies for the hospital and physician group FACULTY: Thom A Mayer, MD, FACEP BIO: Dr. Mayer is Founder and Chief Executive Officer of Best Practices, Inc.; Executive Vice President of EmCare; Medical Director of the NFL Players Association; Clinical Professor of Emergency Medicine at George Washington; Senior Lecturing Fellow, Duke University School of Medicine; Dr. Mayer has served on the Department of Defense on Defense Science Board Task Forces on Bioterrorism, Homeland Security and Consequences of Weapons of Mass Destruction. Dr. Mayer also serves as a Medical Director for the Studer Group.; ACEP Outstanding Speaker of the Year 1989-90. DISCLOSURE: (*)Salary : Envision Physcian Services Royalty : Health Administration Press, McGraw-Hill

American College of Emergency Physicians Emergency Department Directors Academy PRESENTS THE BUSINESS CASE FOR FLOW THOM MAYER, MD, FACEP, FAAP, FACHE MEDICAL DIRECTOR, NFL PLAYERS FOUNDER, BEST PRACTICES SENIOR FELLOW, DUKE UNIVERSITY CLINICAL PROFESSOR OF EM, GWU

Agenda We work in an increasingly capacity-constrained environment requiring resourcefulness and expertise in change leadership In that environment, value trumps volume, but volume creates demand-capacity problems Flow improves safety, service and operating costs Flow allows us to serve more patients, serve them better and make our jobs easier The latter gives substantial competitive advantage in talent arbitrage You ve already heard from some Superstars 2 TM

From To

Connect the Gears Shared Mental Models Rule #1, Rule #2 Rule #3 CLINICAL EFFECTIVENESS PATIENT SAFETY PATIENT PATIENT EXPERIENCE HARDWIRING FLOW 4 TM

But Dr. Mayer, I m working so hard! Don t work hard, work easy! 1 st job of a leader 5 TM

Every system is perfectly designed to get precisely the results it gets. Dr. Paul Batalden 6 TM

The Fundamental Problem? The way we re working Isn t working! 7 TM

What are YOUR... Biggest Flow Issues?

HARDWIRING FLOW Adding Value, Eliminating Waste

Hardwiring the Definition of Flow Flow is defined as adding value and decreasing waste to processes, services or behaviors by increasing benefits, decreasing burdens, (or both) when applied to the movement of our patients through our service transitions and queues

The Value-Added Equation What are the BENEFITS RECEIVED? OBVIOUS? Re-affirm them NON-OBVIOUS? Inform them What are the BURDENS ENDURED? NECESSARY? Explain them UNNECESSARY? Eliminate them (Waste) 11 T. Mayer, K. Jensen TM

Becoming a Flow Detective A continuous Treasure Hunt to Add Value A continuous Bounty Hunt to Eliminate Waste (anything which doesn t add value) 12 2017 Huron Consulting Group Inc. and Affiliates. All Rights Reserved.

What s at Stake in Improving Flow? Improved financial return by increasing capacity Shortened time intervals by eliminating waste Identification and removal of bottlenecks Improved patient and clinician experience Increased safety by reducing non-value added variation Improved clinical outcomes and reliability Reduced costs by decreasing non-value-added steps It makes our jobs easier

Flow and the 6 Rights Right resources for Right patient in the Right environment (bed) for the Right reasons at the Right time Every time! 14 2017 Huron Consulting Group Inc. and Affiliates. All Rights Reserved.

Finding Flow Taking people out of their comfort zones Getting them with you on the takeoff Finding flow requires Asking Why and Why Not? Incessantly $ Drive 516 Million Specialist Visits Creating hope Catalyzing reactions 15 T. Mayer, K. Jensen KJ

MONETIZING FLOW The Benefits Of Flow To Your Bottom Line

ED Myths you Must Dispel We lose money in the ED. The ED is a loss leader. We don t want more ED visits. The real money is in elective procedures. EDs cost far too much. We need to get rid of 50% of non-emergencies.

The Business Case for Flow Continued Why This (Should) Matter to Nurses Facility fees are not nearly as well-defined as ProFees Typically include room charges, medical supplies, some diagnostic tests (imaging, lab, POC) Some services not under the provider fee Medications APCs and E/M codes are tightly cross-walked Facility fees are usually 3-5 times what the physician charges Sutton s Law and FSEDs 18

EDs as Profit Centers Not Loss Leaders E/M Professional Fees 99281 $21.60 99282 $42.12 99283 $63.00 99284 $119.52 99285 $176.04 99291 $226.00 APC/FacilityFees 5021 $61.34 5022 $111.42 5023 $201.17 5024 $332.27 5025 $488.53 5041 $686.87

5 Key Demand-Capacity Questions 1. Who s coming? 2. When are they coming? 3. What are they going to need? 4. Are we going to have it? 5. What will we do if we don t?

EDBA Data Total Sites Hi EMS LOS LOS Door EKG Xray CT MRI % Hosp Visits Visits Peds Admit Transfer EMS Median LOS LBT Admit CPT Arrival Treat & Fast to per per per per Admits per Beds per % % % Arrival LOS Admit C Time Acuity Release Track Doc 100 100 100 100 thru ED Foot Space Admit Total All EDs 2012 results 991 64% 21.2% 16.6% 2.0% 16% 40% 171 147 111 288 2.2% 32 26 48 20 1.0 68% 3.1 27 1,602 119 31 66% 22.3% 18.6% 0.8% 21% 39% 233 195 134 387 3.2% 49 31 43 19 1.1 67% 4.1 71 1,623 161 42 69% 23.8% 20.3% 0.9% 18% 45% 219 185 117 363 3.4% 41 26 48 22 0.9 65% 3.4 53 1,720 165 110 66% 20.6% 19.6% 1.2% 19% 42% 201 170 116 335 2.7% 39 31 50 24 1.8 65% 3.1 44 1,643 142 207 67% 18.1% 19.4% 1.6% 19% 43% 187 160 113 303 2.5% 33 30 50 24 1.2 68% 3.4 31 1,671 121 350 63% 22.1% 15.8% 1.9% 15% 38% 163 139 101 271 2.0% 30 23 48 19 0.8 68% 3.1 19 1,667 104 250 60% 22.7% 12.1% 3.3% 12% 35% 137 118 73 236 1.4% 24 20 44 16 0.3 71% 2.4 10 1,348 83 31 50% 88.4% 10.5% 0.9% 8% 30% 146 130 100 260 1.3% 30 5 31 5 0.3 68% 4.0 23 1,924 95 70% 1.1% 23% 48% 241 199 129 359 3.4% 46 34 49 25 1.3 62% 3.2 38 1,420 179 2.7% 8% 31% 114 107 53 250 1.0% 20 19 19 14 0.0 67% 2.4 12 1,510 93 Over 100K EDs 2012 results 80 to 100K EDs 2012 results 60 to 80K EDs 2012 results 40 to 60K EDs 2012 results 20 to 40K EDs 2012 results Under 20K EDs 2012 results Pediatric EDs 2012 Results Adult, Specialty EDs 2012 Results 31 3.0% 24.7% Urgent Care, Freestanding EDs 2012 Results 52 52% 21.0% 8.4%

The Flow Cascade A Set of Solutions to ED Flow Input Throughput Output Triage Bypass Bedside Registration Early Decision to Admit Advanced Triage/Initiatives Fast Track Door to Discharge Program Team Triage and Treatment (T3) Level 3 Fast Track Express Admission Units Provider in Triage (PIT) Supertrack/Ultratrack ICU Fast Tracking Patient Segmentation Results Waiting Room Dedicated Discharge Process Vertical 3 Fast Track Be A Bed Ahead

Leverage Where to hit with the hammer?

Leveraging Flow Flow Initiative Triage Bypass AT/AI True segmentation-value streams Pivot Nurse PIT Team Triage Ultratracks Vertical 3 Fast Tracks Results Waiting Room Organ Grinder/Monkey

Leveraging Flow Flow Initiative Early Decision to Admit HM Comes to ED Early Request for a Bed Admitting Agreements Express Admitting Units ICU Fast Tracking Adopt-A-Boarder Discharge by 10 Organ Grinder/Monkey

Hardwiring Flow-Triage Adds Value DOES TRIAGE... 1. Improve throughput? 2. Increase safety? 3. Improve satisfaction? 4. Improve quality? 5. Provide information? 6. Increase revenue? If not Why not Change It NOW! 26 T. Mayer, K. Jensen TM

Patient Streaming, Segmentation and Flow 27

Not all ESI 3s are the same Vertical Sitting, standing Non-severe pain Extremity lacerations < 1 liter of fluids, oral Headache (not worst in life) No active vomiting/diarrhea Back pain, no fever Vaginal spotting Minor epistaxis Non-displaced MSK Horizontal Needs to lay down More severe pain Complex lacerations > 1 liter of IV fluids Severe headache Active vomiting or diarrhea Altered mental status Needs monitoring GI bleeding Propriety

You have to open the back door of the ED to the hospital if you want to have any hope of keeping the front door of the ED open to the community and EMS.

How Can You Tell a "Push" vs. "Pull" "Push" Systems Language "Do you have a bed?" "Can you take a patient?" We have 6 boarders-can you help us?" "We're on rounds-we can't talk" "This is not a good time for us to take a patient." "What do expect us to do?" 30 "Pull" Systems Language "I saw on the bed board you have 10 boarders in the ED. We can take 3-1 now and 2 in 30 minutes." "What can we do to help?" "We won't have an ICU bed for an hour but I'll send an RN now" We're on rounds, but I'll have a nurse break out and come now."

Waste-Example At 2 PM, a patient is discharged from a med-surg floor at your hospital Who puts the bed back in service? What steps need to be taken to do that? What are the rate-limiting steps/bottlenecks? What is the incentive to do so? 31

Do Your If Not, Why Not? Hospitalists care about ED boarders, LOS, patient satisfaction? Emergency physicians care about Hospital bed turns, LOS, core measure compliance, finances, readmissions? Radiologists care about Oral contrast in abdominal CTs, plain film TAT?

Hospital-Wide Flow Early Decision to Admit- In or Out? Early Request for a Bed-Be a Bed Ahead Intelligent Bed Management Rapid Admission Process Express Admitting Units ICU Fast Tracking Adopt-a-Boarder Real-Time Demand-Capacity Management 33

34 Early Decision to Admit In most cases, an experienced emergency physiciannurse team knows within minutes following the initial assessment whether a patient will need admission Diagnostic testing is sometimes necessary to determine the type of bed (Obs, Floor, Tele ) Delaying admission until every lab and x-ray is back is an unrealistic expectation in flow Early consultation is often resisted Right patient, right bed, right team, right time Can be disruptive to the flow of the admitting team No or Not yet Good for the patient?

Early Request For A Bed As soon as the needed bed type becomes clear, the emergency physician should consider ordering an inpatient bed In hospitals where it takes 30 minutes or longer to get a bed, early bed requests can be an important part of your strategy In hospitals where bed assignment takes only minutes, this step may be unnecessary In the early request for a bed strategy, the in-patient bed management process occurs concurrently with the E.D. s diagnostic and therapeutic processes An example of parallel rather than sequential processing Data drives the train 35

Intelligent Bed Management Process Goals Adding accuracy Improving cooperation and teamwork across boundaries Reducing variation and improving reliability Making a system a system Outcome Goals Efficiently and effectively place the patient in the right unit with the right skills, with the right staffing ("Best Fit") Facilitate the acceptance of the patient by the unit ("Pull" vs. "Push") Results measured across units-system results 36

Admitting Agreements The E.D. should not be held hostage to the work flow of the admitting physicians Office-based physicians often come to admit ED patients after their office hours are over, resulting in multi-hour ED stays With residency and hospitalist admissions, the admitting teams often tell the emergency physician that they will get to the ED when we can Surgical services may be in the O.R. for hours before responding to the ED Admitting agreements, understandings or policies should be in place that allow the ED to send stable patients to the floor for evaluation by the admitting team Where there are consult delays, the workup will take place on the inpatient floor and NOT in the ED A policy to assure adequate workup and stability in the ED is useful, perhaps necessary This is all admittedly harder to accomplish than it seems But We ve always done it that way is no longer a luxury patient/team can afford! 37

Admitting Agreements E.D. Direct Admissions Checklist Case discussed with admitting team. Name of admitting physician consulted. Time of consult AM/PM Patient may go to floor at AM/PM (1 hour from time of consult; or sooner if approved by the admitting team). E.D. attending has signed the Direct Admission Orders. Patient has no diagnostic exclusion criteria. Diagnostic Exclusion Criteria a) Undiagnosed abdominal pain unless abdominal imaging completed (CT or US) or case discussed with surgery team. b) Patients who require intensive or progressive care. c) Patients who do not have a primary surgical diagnosis. d) Patients who require emergent operation or procedure. E.D. Physician Signature

Express Admitting Units (EAUs) And ED Holding Areas Busy E.D.s need to decompress before the number of boarders starts to grow. EAUs and Holding Areas are often geographically separate from the ED but usually located nearby. The size of these units varies according to the number of ED admissions per day; usually from 5 to 15 beds (although some large EDs may have a 25 or 30 bed observation unit.) Stable ED patients who require admissions are moved to a staging area (the EAU) using holding orders to await further evaluation and formal admission by the admitting team. After evaluation, admitting service can select the most appropriate inhospital bed. In some hospitals the EAU patients are the responsibility of the admitting team while the ED Hold patients remain the responsibility of the ED team until the arrival of the admitting physician. EAU and ED Hold nurses must be relentless in their pursuit of admitting orders from the in-patient team and fast-tracking the preliminary diagnostic and treatment plan. 39

Transition/ GAP/ Bridge Orders A Few Comments Transition/Gap/Bridge orders can decrease time to admission and decrease E.D. LOS. Holding orders are part of the emergency medicine practice in many E.D.s. (Patterson J. Dutterer L. Rutt M. et. Al. Bridging orders and a dedicated admission nurse decreases emergency department turnaround times while increasing patient satisfaction Ann Emerg Med. 50(3):351-2,2007 Sep.) Holding orders are NOT admission orders. Holding or Bridging orders are time-limited orders that permit stable patients to be moved safely from the ED to an inpatient setting or holding unit. In the past, some experts believed that Emergency Physicians should NOT write admission orders as it could unnecessarily extend their medico-legal liability to the inpatient setting. However, current thinking suggests that there is little additional legal risk for the emergency physician who writes holding orders. Holding orders must be properly written. The orders should make clear that the inpatient team is responsible for all further orders and the admitting team (and NOT the emergency physician) must be notified of any change in the patient s condition. Below, the current position statements of AAEM and ACEP: The American Academy of Emergency Medicine states that The Academy believes that it is acceptable for emergency physicians to write Holding Orders, which define any necessary treatment and assessment parameters required in the interval until completion of admission orders. (http://www.aaem.org/positionstatements/admissions.php). In their April 2010 policy revision, the American College of Emergency Physicians (ACEP) stated; in the interest of patient care and safety, an emergency physician may be compelled to write transition orders. These transition orders may include essential treatment and assessment parameters required before preparation of suitable admission orders. (ACEP Policy Writing Admission and Transition Orders April 2010) There appears to be more legal risk in boarding patients in an overcrowded E.D. than in using holding orders. 40

ICU Management ICU patients in the E.D. consume significant amounts of nursing and physician resources and divert monitoring and care from other patients in the E.D. There is also a correlation with the duration of time an ICU patient remains in the ED and subsequent mortality, especially for ED stays longer than 6 hours. (Chalfin DB, et. Al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35:1477-1483.) Consider ICU Fast-Tracking 41

ICU Fast-Tracking One Example POLICY A Critical Care Alert can be called for patients meeting the following inclusion criteria: Sepsis/Sepsis syndrome Acute respiratory failure requiring mechanical ventilation Resuscitation post-arrest Unstable hemodynamics requiring vasopressor intervention Intracranial hemorrhage with evolving neurological deficits or airway compromise Patients meeting inclusion criteria will have a Critical Care Alert called at the time they are recognized to meet inclusion criteria. A 30 minute response time (from notification to arrival in ED) is required from patient s physician or the intensivist. Critical Care Unit will respond within 30 minutes of notification with both a bed assignment and a team for transporting the patient to Critical Care. All immediate diagnostic radiology needs should be completed prior to transport. The patient s E.D. nurse will accompany the team to the Critical Care Unit to give bedside report. 42

Adopt-A-Boarder Program Started independently at Inova Fairfax Hospital and in Stonybrook, this practice has spread to many of the largest hospitals in the United States, including Duke, William Beaumont, and UCLA Admitted patients routinely spend hours in the ED hallway while they await an inpatient bed On a busy day an ED can have up to 10 patients at any one time in their hallway awaiting bed placement Some patients wait 12 hours or more in the hall Instead of having all 10 patients wait in a single hallway in the ED, what if we placed 1 patient each in 10 different hallways on inpatient wards? Would they get better care? Would they be more satisfied with their boarding stay? Admitted ED patients very much preferred the inpatient hallway to the ED hallway Adopted boarders felt they got more personal attention and better care in the inpatient hallways than in the ED. Nearly all patients stated that they were happy to be closer to their inpatient bed Studies from Stonybrook, Inova hospitals, and UCLA showed that the Adopt-a- Boarder program accelerated bed turnover Many patients who were destined for an inpatient hallway bed instead went straight to their inpatient rooms Beds were cleaned in a fraction of the usual time Patient satisfaction with the program was extremely high at all hospitals studied Further discussion of this program can be found at http://www.hospitalovercrowding.com/ 43

Focus On Your Key Leverage Points: Demand-Capacity Analysis & Management: Planning for your critical servers Docs (APPs), Nurses and Beds (Treatment Spaces) Getting it right on average Managing peak loads Leveraging your ED s Points of Entry - Optimizing the value and impact of Triage and the Front End of Your ED Segmenting and Fast-Tracking your incoming patient streams Efficiently and Effectively Fast-Tracking Your Low-Acuity Patients: ESI 5s and 4s Mid-Acuity Management - ESI Level 3 Fast Tracking A Plan and Process for Your High-Acuity Patients Leveraging Teams and Team-Based Care Addressing flow Into, Through, and Out of your Hospital

Critical ED Patient Flow Concepts Front-Load Flow-The front door and your front end processes drive flow Triage is a process, not a place Get the patient and the doctor together as quickly and efficiently as possible Get the (right) patient to the (right) doctor/team as quickly and efficiently as possible The more horizontal you are, the more you are a patient-the more vertical, the more you are a customer Keep your vertical patients vertical and in motion For horizontal patients, real estate matters; for vertical patients, speed matters

Critical ED Patient Flow Concepts-2 Patients who do not require many resources should not wait behind patients who do, no matter how high the volume of patients in the ED Fast Track is a verb, not a noun The MVP of the ED is the Bed! Be fast at fast things and slow at slow things The #1 sign of the health of the ED is the relationship between the doctors and nurses Making people unhappy, making them wait without explanation, and then sending them a bill is a bad business model!

We were having so much fun We couldn t wait to get up in the morning!

Benchmarking Resources Where to find data Your neighbors Call and/or visit ACEP http://www.acep.org Premier www.premier.com VHA www.vha.com ED Benchmarking Alliance www.edbenchmarking.org UHC www.uhc.org Be sure to compare hospitals with similar acuity and similar volume

References Arthur, J. Lean Six Sigma for Hospitals. New York, McGraw-Hill: 2011. Arthur, J. Lean Six Sigma DeMYSTIFIED: a Self-Teaching Guide. New York, NY, McGraw Hill: 2006. Arthur, J. Lean Six Sigma: Simple Steps to Fast, Affordable, Flawless Healthcare. New York, NY, McGraw Hill: 2011. Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): 1113-1118. Berry, LL, Seltman, K. Management Lessons from Mayo Clinic. New York, McGraw-Hill: 2008. Berry, LL. Discovering the Soul of Service. New York, NY, The Free Press: 1999. Bisognano, M, Kenney, C. Pursuing the Triple Aim: Seven Innovators to Show the Way to Better Care, Better Health, and Lower Costs. San Francisco, CA, John Wiley & Sons: 2012. Black, J. Transforming the patient care environment with lean six sigma and realistic evaluation. J Health Qual 2009; 31-29-35. Black, J, Miller, D. The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean. Chicago, IL, Health Administration Press, 2008. Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C. 2000. Caldwell, C. et al. Lean-Six Sigma for Healthcare: A Senior Leader Guide to Improving Cost and Throughput. Milwaukee, WI, Quality Press: 2005. Chalice, R. Improving Healthcare Using Toyota Lean Production Methods. 2nd ed. Milwaukee, WI: ASQ Quality Press, 2007. Christensen, C, J Grossman, and J Hwang. The Innovator's Prescription: A Disruptive Solution for Health Care. New York, NY, McGraw-Hill: 2009.

References Cottington, S, Forst, S. Lean Healthcare: Get Your Facility into Shape. Marblehead, MA, HCPro: 2010. Crane, J, Noon, C. The Definitive Guide to ED Operational Improvement. New York, NY, CRC Press: 2011. Dickson, E, et al. Application of lean manufacturing techniques in the emergency department. J Emerg Med 2009; 37:177-82. Dickson, EW, et al. Use of lean in the emergency department: A case series of 4 hospitals. Ann Emerg Med 2009; doi:10.1016/j.annemergmed.2009.03.024 Doing More with Less: Lean Thinking and Patient Safety in Health Care. 2006, Joint Commission Resources. Fitzsimmons J., and M. Fitzsimmons. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill: 2006. Forster, Alan, et al. "The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition." Academy of Emergency Medicine 10.2 (2003): 127-133. Full Capacity Protocol. www.viccellio.com/overcrowding.htm Gawande, Atul. The Checklist Manifesto-How to Get Things Right. New York, NY, Metropolitan Books: 2009. Goldratt, E. The Goal. Great Barrington, MA, North River Press: 1986. Graban, M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY, Productivity Press: 2009. Hadfield, D, et al. Lean Healthcare-Implementing 5s in Lean or Six Sigma Projects. Chelsea, MI, MCS Media: 2006.

References Holland, L., L. Smith, et al. 2005. Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay. Am J Clin Pathol 125 (5): 672-674. Husk, G., and D. Waxman. 2004. Using Data from Hospital Information Systems to Improve Emergency Department Care. SAEM 11(11): 1237-1244. Institute for Healthcare Improvement (IHI). Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. Innovation Series 2003. Bursting at the Seams: 2004. Improving Patient Flow to Help America s Emergency Departments. Urgent Matters Learning Network Whitepaper. www.gwhealthpolicy.org accessed September 17, 2005. Jensen, Kirk and Thom Mayer. Hardwiring Flow: Systems and Processes for Seamless Patient Care. Gulf Breeze, FL, Fire Starter Publishing: 2009. Jensen, Kirk, and Jody Crane. "Improving patient flow in the emergency department." Healthcare Financial Management Nov. 2008: I-IV. Jensen, Kirk, Thom Mayer, Shari Welch, and Carol Haraden. Leadership for Smooth Patient Flow. Chicago, IL, Health Administration Press: 2007. Jensen, Kirk. Expert Consult: Interview with Kirk Jensen. ED Overcrowding Solutions Premier Issue. Overcrowdingsolutions.com. 2011. Kaplan, RS, Porter, M. The Big Idea: How to Solve the Cost Crisis in Healthcare. Harvard Business Review, 2011, Sept 1. Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130:373-375. Krafci, JF. Triumph of the Lean Production System. Sloan Management Review 1988; 30: 41-45. Lee, Thomas. Chaos and Organization in Health Care. Cambridge, MA, MIT Press: 2009.

References Maister, D. The Psychology of Waiting Lines. In J. A. Czepiel, M. R. Solomon & C. F. Surprenant (Eds.), The Service encounter: managing employee/customer interaction in service businesses. Lexington, MA: D. C. Heath and Co, Lexington Books. 1985. Mayer, Thom. Applying the Principles of Lean Management to Healthcare. PowerPoint Presentation, BestPractices, Inc. 2011. Mayer T, Jensen K. Flow and return on investment in healthcare. 2008, Int J Six Sigma and Comp Adv, 4: 192-195. Mayer, Thom, and Jensen Kirk. "The Business Case for Patient Flow." Healthcare Executive July-Aug. 2012: 50-53. Mayer, Thom, and Robert Cates. Leadership for Great Customer Service: Satisfied Patients, Satisfied Employees. Chicago, IL: Health Administration Press: 2004. Meade, Christine, Julie Kennedy, and Jay Kaplan. "The Effects of Emergency Department Staff Rounding on Patient Safety and Satisfaction." JEM 2010; 38.5: 666-674. Norman, D. A. Designing waits that work. MIT Sloan Management Review 2009; 50.4:23-28. Norman, D. A. The Psychology of Waiting Lines. PDF version is an excerpt from a draft chapter entitled "Sociable Design" for a new book-www.jnd.org/dn.mss/the_psychology_of_waiting_lines. 2008. Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.ihi.org). Richardson, DB. The Access Block Effect: Relationship between Delay to Reaching an Inpatient Bed and Inpatient Length of Stay. Med J Australia 2002; 177:492. Savary, L, Crawford-Mason, C. The Nun and the Bureaucrat: How They Found an Unlikely cure for America s Sick Hospitals. Washington, DC, CC-M Productions: 2006.

References Schull et al. Emergency Department Contributors to Ambulance Diversion: a Quantitative Analysis. Annals of Emergency Medicine 41:4 April 2003; 467-476. Serrano, L, Slunecka, FW. Lean processes improve patient care. Healthcare Executive 2006; 21: 36-38. Shook, J. Managing to Lean: Using the A3 management process to solve problems, gain agreement, mentor and lead. Cambridge, MA, Lean Enterprise Institute: 2008. Smith, A. et al. Going Lean, Busting Barriers to Patient Flow. Chicago, IL, Health Administration Press: 2008. Spear, S. Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win. New York, NY, McGraw Hill: 2009. Spears, S. Learning to Lead at Toyota. Harvard Business Review, 2004; 82:78-86 Toussaint, J, Gerard, R. On the Mend. Cambridge, MA, Lean Enterprise Institute: 2011. Wilson, M., and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America s Emergency Departments. Urgent Matters White Paper. September, 2004. Womack, J, Jones, D. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York, NY, Simon & Schuster: 1996.

Flow Resources 54

The Patient Flow Advantage: How Hardwiring Hospital-Wide Flow Drives Competitive Performance Section 1 Framing the Flow Mandate Chapter 1: Why Flow Matters Chapter 2: Defining Flow: Establishing the Foundations Chapter 3: Strategies and Tools to Hardwire Hospital-Wide Flow Chapter 4: Lessons from Other Industries Kirk Jensen/Thom Mayer FireStarter Publishing, January 2015 Section 2 Advanced Flow Concepts Chapter 5: Emergency Department Solutions to Flow: Fundamental Principles Chapter 6: Advanced Emergency Department Solutions to Flow Chapter 7: Hospital Systems to Improve Flow Chapter 8: Hospital Medicine and Flow Chapter 9: Real-Time Demand and Capacity Management Section 3 Frontiers of Flow Chapter 10: Hardwiring Flow in Critical Care Chapter 11: Smoothing Surgical Flow Chapter 12: Acute Care Surgery and Flow Chapter 13: Integrating Anesthesia Services into the Flow Equation Chapter 14: The Role of Imaging Services in Expediting Flow Chapter 15: The Future of Flow 55

Hardwiring Flow Systems and Processes for Seamless Patient Care Thom Mayer, MD, FACEP, FAAP Kirk Jensen, MD, MBA, FACEP Why patient flow helps organizations maximize the Three Es : Efficiency, Effectiveness, and Execution How to implement a proven methodology for improving patient flow Why it s important to engage physicians in the flow process (and how to do so) How to apply the principles of better patient flow to emergency departments, inpatient experiences, and surgical processes 56

Table of Contents Emergency Department Leadership and Management Best Principles and Practice Editors: Stephanie Kayden, Brigham and Women s Hospital, Harvard Medical School, Boston Philip D. Anderson, Brigham and Women s Hospital, Harvard Medical School, Boston Robert Freitas, Brigham and Women s Hospital, Harvard Medical School, Boston Elke Platz, Brigham and Women s Hospital, Harvard Medical School, Boston Cambridge University Press: November 2014 Foreword Gautam G. Bodiwala Part I. Leadership Principles: 1. Leadership in emergency medicine Robert L. Freitas 2. Identifying and resolving conflict in the workplace Robert E. Suter and Jennifer R. Johnson 3. Leading change: an overview of three dominant strategies of change Andrew Schenkel 4. Building the leadership team Peter Cameron 5. Establishing the emergency department's role within the hospital Thomas Fleischmann 6. Strategies for clinical team building: the importance of teams in medicine Matthew M. Rice Part II. Management Principles: 7. Quality assurance in the emergency department Philip D. Anderson and J. Lawrence Mottley 8. Emergency department policies and procedures Kirsten Boyd 9. A framework for optimal emergency department risk management and patient safety Carrie Tibbles and Jock Hoffman 10. Emergency department staff development Thomas Fleischmann 11. Costs in emergency departments Matthias Brachmann 12. Human resource management Mary Leupold 13. Project management Lee A. Wallis, Leana S. Wen and Sebastian N. Walker 14. How higher patient, employee and physician satisfaction lead to better outcomes of care Christina Dempsey, Deirdre Mylod and Richard B. Siegrist, Jr 15. The leader's toolbox: things they didn't teach in nursing or medical school Robert L. Freitas Part III. Operational Principles: 16. Assessing your needs Manuel Hernandez 17. Emergency department design Michael P. Pietrzak and James Lennon 18. Informatics in the emergency department Steven Horng, John D. Halamka and Larry A. Nathanson 19. Triage systems Shelley Calder and Elke Platz 20. Staffing models - Kirk Jensen, Dan Kirkpatrick and Thom Mayer 21. Emergency department practice guidelines and clinical pathways Jonathan A. Edlow 22. Observation units Christopher W. Baugh and J. Stephen Bohan 23. Optimizing patient flow through the emergency department - Kirk Jensen and Jody Crane 24. Emergency department overcrowding Venkataraman Anantharaman and Puneet Seth 25. Practice management models in emergency medicine Robert E. Suter and Chet Schrader 26. Emergency nursing Shelley Calder and Kirsten Boyd Part IV. Special Topics: 27. Disaster operations management David Callaway 28. Working with the media Peter Brown 29. Special teams in the emergency department David Smith and Nadeem Qureshi 30. Interacting with prehospital systems Scott B. Murray 31. Emergency medicine in basic medical education Julie Welch and Cherri Hobgood 32. Emergency department outreach Meaghan Cussen 33. Planning for diversity Tasnim Khan Index. 57

By Robert W. Strauss MD, Thom A. Mayer, MD, Chief editors Kirk B Jensen, MD, MBA, FACEP, Associate Editor ISBN-13: 9780071762397 Publisher: McGraw-Hill Professional Publication date: January 2014 Strauss and Mayer's Emergency Department Management Thom Mayer, one of two chief editors, co-authored 20+ chapters Kirk Jensen, one of two associate editors, co-authored 11 chapters as well as serving as section editor of the Operations: Flow section. Relevant chapters on patient flow, patient safety, risk management, teamwork, culture change, and leadership development 58

Table of Contents, Patient Flow: Reducing Delay in Healthcare Delivery, Second Edition : Patient Flow: Reducing Delay in Healthcare Delivery, Second Edition Randolph Hall, PhD Editor Springer, January 2014 1. Modeling Patient Flows Through the Healthcare System, RANDOLPH HALL, DAVID BELSON, PAVAN MURALI AND MAGED DESSOUKY 2. Hospital-wide System Patient Flow-ALEXANDER KOLKER 3. Hospitals And Clinical Facilities, Processes And Design For Patient Flow MICHAEL WILLIAMS 4. Emergency Department Crowding-KIRK JENSEN 5. Patient Outcomes Due to Emergency Department Delays- MEGHAN MCHUGH 6. Access to Surgery and Medical Consequences of delays BORIS SOBOLEV, ADRIAN LEVY AND LISA KURAMOTO 7. Breakthrough Demand-Capacity Management Strategies to Improve Hospital Flow, Safety, and Satisfaction-LINDA KOSNIK 8. Managing Patient Appointments in Primary Care-SERGEI SAVIN 9. Waiting Lists for Surgery-EMILIO CERDÁ, LAURA DE PABLOS, MARIA V. RODRÍGUEZ-URÍA 10.Triage and Prioritization for Non-Emergency Services-KATHERINE HARDING 11.Personnel Staffing and Scheduling-MICHAEL WARNER 12.Discrete-Event Simulation Of Health Care Systems SHELDON H. JACOBSON, SHANE N. HALL AND JAMES R. SWISHER 13.Using Simulation to Improve Healthcare: Case Study-BORIS SOBOLEV 14.Information Technology Design to Support Patient Flow KIM UNERTL, STUART WEINBERG 15.Forecasting Demand for Regional Healthcare-PETER CONGDON 16.Queueing Analysis in Healthcare -LINDA GREEN 17.Rapid Distribution of Medical Supplies - MAGED DESSOUKY, FERNANDO ORDÓÑEZ, HONGZHONG JIA, AND ZHIHONG SHEN 18.Using a Diagnostic to Focus Hospital Flow Improvement Strategies ROGER RESAR 19.Improving Patient Satisfaction Through Improved Flow- KIRK JENSEN 20.Continuum of Care Program- MARK LINDSAY 21.A Logistics Approach for Hospital Process Improvement-JAN VISSERS 22.Managing a Patient Flow Improvement Project-DAVID BELSON 59

Leadership for Smooth Patient Flow: Improved Outcomes, Improved Service, Improved Bottom Line Kirk B. Jensen, MD, FACEP Thom A. Mayer, MD, FACEP, FAAP Shari J. Welch, MD, FACEP Carol Haraden, PhD, FACEP The heart of the book focuses on the practical information and leadership techniques you can use to foster change and remove the barriers to smooth patient flow. You will learn how to: Break down departmental silos and build a multidisciplinary patient flow team Use metrics and benchmarking data to evaluate your organization and set goals Create and implement a reward system to initiate and sustain good patient flow behaviors Improve patient flow through the emergency department the main point of entry into your organization The book also explores what healthcare institutions can learn from other service organizations including Disney, Ritz-Carlton, and Starbucks. It discusses how to adapt their successful demand management and customer service techniques to the healthcare environment. This book marks a milestone in the ability to explain and explore flow as a central, improvable property of healthcare systems. The authors are masters of both theory and application, and they speak from real experiences bravely met. Donald M. Berwick, MD President and CEO Institute for Healthcare Improvement (from the foreword) ACHE + Institute for Healthcare Improvement 60

The Hospital Executive s Guide to Emergency Department Management Kirk B. Jensen, MD, FACEP Daniel G. Kirkpatrick, MHA, FACHE Table of Contents: Chapter 1: A Design for Operational Excellence Chapter 2: Leadership Chapter 3: Affordable Care Act Impact What Healthcare Reform Means for the ED Chapter 4: The Impact of Specialized Groups and Populations on the ED Chapter 5: Fielding Your Best Team Chapter 6: Improving Patient Flow Chapter 7: Ensuring Patient Satisfaction Chapter 8: Implementing the Plan Chapter 9: Culture and Change Management Chapter 10: Patient Safety and Risk Reduction Chapter 11: The Role and Necessity of the Dashboard Chapter 12: Physician Compensation: Productivity-Based Systems Chapter 13: Billing, Coding, and Collections Chapter 14: The Business Case HcPro April 2014 61

Managing Patient Flow in Hospitals: Strategies and Solutions, Second Edition 62

The Definitive Guide to Emergency Department Operational Improvement 63

64 Making Healthcare Work Better with Lean Text and Workbook Authored by: EmCare Clinicians and Operational Experts Foreword: Kirk Jensen Sample Chapters: Applying Lean to Healthcare Lean Requires Transformation Lean System: Integrating Clinical Departments Lean Emergency Department Lean OR Lean in the Surgery Schedule Lean Inpatient Lean Transitions Lean Beyond the Hospital Stay Lean Radiology Lean Ancillary Services Lean Processes for Leaders 2016 EmCare

Improving Patient Flow In the Emergency Department Kirk Jensen Jody Crane 65

Real-Time Demand Capacity Management And Hospital-Wide Patient Flow The Joint Commission Journal on Quality and Patient Safety: May 2011 Volume 37 Number 5 66

Improving Patient Flow Through a Better Discharge Process J Healthc Manag. 2012 Mar-Apr;57(2):89-93. Improving patient flow through a better discharge process. Johnson M, Sensei L, Capasso V. 67

EmCare Door-to-Discharge 68

The Improvement Guide and Rapid-Cycle Testing Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. 69

References Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): 1113-1118. Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C. 2000. Christensen, C, J Grossman, and J Hwang. The Innovator's Prescription: A Disruptive Solution for Health Care. 2009. Fitzsimmons J., and M. Fitzsimmons. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill. 2006. Full Capacity Protocol. www.viccellio.com/overcrowding.htm Goldratt, E. The Goal. Great Barrington, MA: North River Press, 1986. Holland, L., L. Smith, et al. 2005. Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay. Am J Clin Pathol 125 (5): 672-674. 70

References Husk, G., and D. Waxman. 2004. Using Data from Hospital Information Systems to Improve Emergency Department Care. SAEM 11(11): 1237-1244. Jensen, Kirk. Expert Consult: Interview with Kirk Jensen. ED Overcrowding Solutions Premier Issue. Overcrowdingsolutions.com. 2011. Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130:373-375. Langley J, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide. 2 nd Edition. San Francisco: Jossey-Bass 2009. Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.ihi.org). Wilson, M., and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America s Emergency Departments. Urgent Matters White Paper. September, 2004. 71

References The Psychology of Waiting Fitzsimmons J., and M. Fitzsimmons. 2006. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill. Maister, D. (1985). The Psychology of Waiting Lines. In J. A. Czepiel, M. R. Solomon & C. F. Surprenant (Eds.), The Service encounter: managing employee/customer interaction in service businesses. Lexington, MA: D. C. Heath and Company, Lexington Books. Meade, Christine, Julie Kennedy, and Jay Kaplan. "The Effects of Emergency Department Staff Rounding on Patient Safety and Satisfaction." JEM 2010; 38.5: 666-674. Norman, D. A. (2008) -- The Psychology of Waiting Lines The PDF version is an excerpt from a draft chapter entitled "Sociable Design" for a new bookwww.jnd.org/dn.mss/the_psychology_of_waiting_lines Norman, D. A. (2009). Designing waits that work. MIT Sloan Management Review, 50(4), 23-28. 72

Benchmarking Resources Where to find data: Your neighbors Call and/or visit ACEP http://www.acep.org Premier www.premier.com VHA www.vha.com ED Benchmarking Alliance www.edbenchmarking.org UHC www.uhc.org Be sure to compare hospitals with similar acuity and similar volume 73