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International Case Study:  Improvements in Patient Flow and Satisfaction using a Patient-Centred Approach - Brigham and Women's Hospital, Boston MA
 

International Case Study: Improvements in Patient Flow and Satisfaction using a Patient-Centred Approach - Brigham and Women's Hospital, Boston MA

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Joshua Kosowsky, Clinical Director - Department of Emergency Medicine, Brigham and Women's Hospital, Boston MA delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow ...

Joshua Kosowsky, Clinical Director - Department of Emergency Medicine, Brigham and Women's Hospital, Boston MA delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03

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    International Case Study:  Improvements in Patient Flow and Satisfaction using a Patient-Centred Approach - Brigham and Women's Hospital, Boston MA International Case Study: Improvements in Patient Flow and Satisfaction using a Patient-Centred Approach - Brigham and Women's Hospital, Boston MA Presentation Transcript

    • Improvements in ED Patient Flow & Satisfaction Using a Patient- Centred Approach Joshua M. Kosowsky, MD, FACEP Vice Chair and Clinical Director Department of Emergency Medicine Brigham & Women’s Hospital Assistant Professor, Harvard Medical School
    • | A bit about Brigham and Women’s Hospital • Founded in 1913 • Teaching affiliate of Harvard Medical School • U.S. News and World Report “Top 10” Hospital • 793 inpatient beds • Core service lines include oncology, cardiovascular disease, orthopedics, neuroscience, and women’s health 1
    • | The Emergency Department at BWH • Level I Trauma Center • 60,000 annual visits (adult) • 1 out of 3 patients admitted or placed in observation • 19,000 square feet (undersized by ~50%) • Board certified, EM-trained attending physicians • Highly acclaimed EM residency program 2
    • | Why Emergency Department flow matters • Front-door to the hospital • Strategic imperative to improve access • ED cannot refuse or divert patients • We don’t have a “4-hour rule” in the U.S! 3
    • | Where was our ED in 2009? 4 Length of stay > 5 hours Waiting room time > 1 hour Walk-out rate > 3% Patient satisfaction < 20th percentile Volume stagnant year-over-year
    • | Process improvement in the ED 5 Can’t be done We’re not the problem It’s too chaotic We’re too busy! It won’t matter anyway
    • | Surveying the landscape 6
    • | Emergency Department flow 7 FRONT-END arrival registration triage bed placement MIDDLE diagnostic testing consulting procedures decision-making BACK-END discharge admitting observation boarding
    • | Common themes Leadership support Front-line staff engagement Goal alignment Performance measurement Accountability 8
    • | 9 Redesign team
    • | Impact-effort matrix 10 Effort Impact Eliminate ED boarding Streamline the admitting process Improve diagnostic turn-around times Reduce door-to-doc time
    • | 11 Check-in ED front-end process map • Non-value added steps • Serial processing • Redundancy • Bottlenecks Is this a “Lean” process? Bed assignment Registration Patient arrival Triage Bed placement WAIT WAIT WAIT WAIT WAIT RN sees patient MD sees patient WAIT WAIT
    • | Top 3 opportunities identified 12 (1) Bedside registration (2) Eliminating triage A. “Any patient, any bed” B. “Bed ahead” C. “Clinical greeter (3) Accountable systems
    • | (1) Bedside registration • Simple check-in function on front-end • One less reason for triage! • Reprioritize patients for full registration on the back-end 13
    • | (2) Eliminating (the need for) triage • Why triage in the first place? A. Sort which patients go where B. Prioritize how long patients should wait C. Identify the true emergencies 14
    • | A. “Any patient, any bed” Traditional model Urgent Specialty areas Fast track Acute New model 15 Any patient Any patient Any patient Any patient • Hazards of “mis-triage” • Frequent mismatch of patients and resources • Requires resources and staff training • Must still allow for exceptions
    • | B. “Bed ahead” 16 If bed is available, why wait at all? • Assign patients by rotation system If bed is not available, make a bed available. • Each area responsible for staying “a bed ahead” at all times Have an exception process for extreme census • Emphasis on getting back into rotation
    • | Putting our money where our mouth is … 17
    • | 18 C. “Clinical greeter” • Initially instituted as a transitional role (concession to nursing traditionalists) • Impact on quality measures (e.g., “door-to-EKG”) • Can also do “check-in” (parallel processing) • Huge patient satisfier!
    • | 19 Standard Process Exception Process Patient arrival New process map Check in Bed ahead? Assign bed by by rotation Q Yes No
    • | 20 (3) Accountable systems • Established RN and MD leadership in each area • New Flow Manager role • Rounds with RNs and MDs in each area • Identifies bottlenecks, reallocates resources • Reports directly to RN Director and MD Director
    • | Our own “4-hour rule”
    • | Performance by shift
    • | Performance by physician
    • | 24 So what happened?
    • | Waiting time (door-to-doc) The average wait time declined from 68 minutes in FY10 to 23 minutes in FY12 (a decrease of 64%). More than half of patients are now in a bed within 10 minutes of arrival.
    • | Walk-out rate The average walk-out rate has fallen from over 3% in FY10 to 1.5% in FY12 (a decrease of 50%). Most months, our monthly walk-out rate is around 1%.
    • | Patient satisfaction 27 Percentile Rank - LG PG – Rec’d Date Satisfaction scores for discharged patients has been at or above the 90th percentile for the past 5 quarters.
    • | Patient satisfaction Steady improvement trend in satisfaction scores for admitted patients as well!
    • | 29 ED visit volume 29 ED volume is up more than 2,500 visits per year since redesign has been implemented.
    • | 30 Voice of the patient “ VERY MUCH IMPROVED!!! Can’t compliment enough! 5 STARS” “Best experience I ever had at any hospital - Exceptional !!” “What a transformation!” (Patient comments, 2012)
    • | 31 Challenges • Gaining buy-in of large and diverse staff • Staying the course • Our doors never close while we implement change • Big change inevitably means multiple bumps in the road • Maintaining our academic mission
    • | 32 The road ahead • Continual measurement and refinement • Sustaining change • Focusing on communication, cultural advancement, and staff satisfaction • Broadening the scope of process improvement beyond the four walls of our ED
    • | 33 Summary • Start with something relatively straightforward (e.g., bedside registration) • To bypass triage, must eliminate the NEED FOR triage • Any patient, any bed • Bed ahead • Clinical greeter? • Cement change with systems of accountability
    • | Acknowledgments • Heidi Crim – RN Director, Dept of EM • Ron Walls – Chairman, Dept of EM • Nancy Hickey – Associate Chief Nurse, BWH • Julia Sinclair –VP Clinical Services, BWH • Joe Camillus – Admin Director, Dept of EM • Christine Imperato – Admin Director, Dept of EM • Kristen Kadera – Senior Consultant, CCE • John Rossi – Senior Consultant, CCE 34
    • | Questions? 35
    • | “Drs. Wen and Kosowsky have insightfully crafted a revelation about the workings of modern medicine….It must be read both because most of us sooner or later are bound to seek health care and because the authors provide an important viewpoint for the intensifying nationwide health care debate.” Bernard Lown, MD, Professor Emeritus, Harvard School of Public Health, Nobel Peace Laureate 1985 Thank you!!