Hardwiring Hospital-Wide Flow To Drive Competitive Performance

1. Hardwiring Hospital-Wide Flow To Drive Competitive Performance Thursday, July 9, 2015 | 2:00PM - 3:00PM EST

2. 2 Your Presenters Thom Mayer, MD, FACEP, FAAP CEO, BestPractices Executive VP, EmCare Kirk Jensen, MD, MBA, FACEP CMO, BestPractices Chief Innovation Officer, EmCare TM

3. In the Perpetual Whitewater Of Change, what are the C-suite’s #1 goals?  Becoming the high quality, cost-efficient provider of care  Delivering the Results that Matter  Becoming an Expert Change Accelerator TM© T. Mayer, K. Jensen

4. 4 Shared Mental Models Aligned Strategic Incentives Rule #1, Rule #2… PATIENT Healthcare Environment Team Hospital Medicine Ourselves TM© T. Mayer, K. Jensen

5. 5 Flow and Execution “Some is not a number. Soon is not a time. Somehow is not a strategy.” The Patient Flow Advantage Jensen/Mayer - 2015 The Patient Flow Advantage: How Hardwiring Hospital-Wide Flow Drives Competitive Performance FireStarter Press TM© T. Mayer, K. Jensen

6. HARDWIRING FLOW Adding Value, Eliminating Waste KJ© T. Mayer, K. Jensen

7. 7 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 KJ© T. Mayer, K. Jensen

8. 8 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 KJ© T. Mayer, K. Jensen

9. 9 Becoming a “Flow Detective” • A continuous Treasure Hunt to add value • A continuous Bounty Hunt to eliminate anything which doesn’t add value (waste) TM© T. Mayer, K. Jensen

10. 10 The Dynamic Tension Of Leadership WHY? Why are we doing it THIS way? EXECUTION Value-Added WHY NOT? Why not do it THAT way? AGILITY Waste-Reduction TM© T. Mayer, K. Jensen

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

12. 12 Waste-Example  Who puts the bed back in service?  What steps need to be taken to do that? At 2 PM, a patient is discharged from a med-surg floor at your hospital…  What are the rate- limiting steps or bottlenecks?  What is the incentive to do so? TM© T. Mayer, K. Jensen

13. 13 Do Your… 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? If Not, Why Not? KJ© T. Mayer, K. Jensen

14. MONETIZING FLOW The Benefits Of Flow To Your Bottom Line KJ© T. Mayer, K. Jensen

15. 15 1.9 million $1,086 $9,000 The Cost – It Adds Up In 2007, 1.9 million people – representing 2% of all ED visits – left the ED before being seen. These walk-outs represent significant lost revenue for hospitals. A 2006 study found that each hour of ambulance diversion was associated with $1,086 in foregone hospital revenues. A recent study showed that a 1- hour reduction in ED boarding time would result in over $9,000 of additional revenue by reducing ambulance diversion and patients who left without being seen. Source: Ambulance Diversion: Economic and Policy Considerations, 14 July 2006 Robert M. Williams Annals of Emergency Medicine December 2006 (Vol. 48, Issue 6, Pages 711-712) Retrieved from http://www.annemergmed.com/article/S0196- 0644(06)00621-4/abstract April 29, 2014. KJ© T. Mayer, K. Jensen

16. 16 ER Patients Results 40,000 ED Visits x 1 Hr Reduction in LOS 40,000 Hours of ED Capacity/ Year 40,000 Hours of ED Capacity/ 2 Hours per ED Visit 20,000 potential new visits/year 20,000 new ED visits x $100/visit in physician revenue $2,000,000 new revenue for the group 20,000 new ED visits @ $400/visit for the hospital $8,000,00 new revenue per year for the hospital ER Admissions New hospital admissions at $3,000 - $7500 per admission 1 more admission per day (365) X $3,000-$7500/ patient admission =$1,095,00-2,737,500/year 50% or more of hospital admissions come through the ER *(AHRQ-only 6.2% of admissions through the ED are uninsured) A Case Study There is a Compelling Business Case for Flow- KJ© T. Mayer, K. Jensen

17. 17 Rap & Go - Expediting Admissions Increased Hospital Revenue Admitted Patients Results Freed Up ER Bed Time 30 Hours Average ER Patient LOS 3 Hours Additional New ER Patients Seen 10 Per Day ER Admission Rate 20% New Admissions Per Day 2 New Admissions Per Year 730 Average Hospital Revenue Per Admit $7,500 New Hospital Revenue $5,475,000 KJ© T. Mayer, K. Jensen

18. 18 The 7 Strategies of Hardwiring Flow 1. Demand-Capacity Management 2. Forecasting Demand 3. Real-Time Monitoring of Flow 4. Queuing Theory 5. Managing Variation 6. Eliminating Bottlenecks 7. Flow as a Complex Adaptive System TM© T. Mayer, K. Jensen

19. 19 The Key Questions  Who’s coming?  When are they coming?  What are they going to need?  Is our service capacity going to match patient demand? And what will we do if or when capacity doesn't match patient demand? TM© T. Mayer, K. Jensen

20. 20 Measure and Act on Demand Capacity Issues Emergency Department clinician staffing mapped against patient arrivals and acuity by hour of the day (HOD) ….and day of the week (DOW)… 0 1 2 3 4 5 6 7 8 9 Demand vs. Capacity Main ED Modeled Demand Average Demand Current Staffing Mismatch KJ© T. Mayer, K. Jensen

21. 21 Hardwiring Patient Flow: Critical Patient Flow Tactical Concepts: Part 1  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  “Fast track” is a verb, not a noun  For horizontal patients, real estate matters; for vertical patients, speed matters  The more horizontal you are the more you are a patient... he more vertical you are the more you are a customer... KJ© T. Mayer, K. Jensen Thom Mayer/Kirk Jensen - Hardwiring Flow

22. 22  Keep your vertical patients vertical and in motion  Be fast at fast things and slow at slow things  The number one sign of the health of an ED, OR, PACU, ICU, or hospital floor is the relationship between the physicians and the nurses  Making people unhappy and sending them a bill is not a healthy business model  If your boarding burden is overwhelming, you are….!@!&%#! Thom Mayer/Kirk Jensen - Hardwiring Flow © T. Mayer, K. Jensen Hardwiring Patient Flow: Critical Patient Flow Tactical Concepts: Part 2 KJ

23. 23 Kill Ya’s • Inadequate nurses • Inadequate essential services • Long TAT, lab, imaging • EMR • Medical staff disengaged • Hospitalists vs. Dischargists • Unmotivated staff • Lack of accountability • No BABA • No Adopt A Boarder • Disconnect between the ED and the rest of the hospital Love ‘Ems • Appropriate staffing • Flex staffing • Team-based • Registration a part of the team • Highly metrics-based • Clear idea of success • Clear TAT goals • Service relationship w/essential services • Effective use of MLPs and Residents • Spectra-link phones • Scribes • Hospital-Wide Flow TM© T. Mayer, K. Jensen

24. 24 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! TM© T. Mayer, K. Jensen

25. 25 Patient Dependent Passive Less Choice Control with Us Clarity Customer Economic Independent Choice Discretionary Purchase Control with Them Diffuse - Unclear Thom Mayer, MD & Kirk Jensen, MD PATIENT C U S T O M E R TM© T. Mayer, K. Jensen Keep Vertical Patients Vertical-and Moving!

26. 26 The Flow Cascade A Set of Solutions to Flow Triage Bypass Advanced Triage/Initiatives Team Triage &Treatment (T3) Provider in Triage (PIT) Patient OutputThroughputInput Bedside registration Fast Track Level 3 Fast Track Supertrack/Ultratrack Results Waiting Room Early Decision to Admit Door to Discharge Program Express Admission Units ICU Fast Tracking Dedicated Discharge Process TM© T. Mayer, K. Jensen

27. ACCELERATING FLOW INTO YOUR HOSPITAL KJ© T. Mayer, K. Jensen

28. 28 Hospital-Wide Flow and the Myth of 100% Utilization Small changes in utilization can lead to big changes in service and throughput Courtesy Chuck Noon, PhD, PEMBA KJ© T. Mayer, K. Jensen

29. PARTNERING WITH HOSPITAL MEDICINE KJ© T. Mayer, K. Jensen

30. 30 Hospital-Wide Flow Options Early Decision to Admit-“In or Out?” Early Request for a Bed-Be a Bed Ahead EBM Bed Selection (EKG and POC Troponin) Rapid Admission Process Express Admitting Units ICU Fast Tracking Adopt-a-Boarder Real-Time Demand-Capacity Management KJ© T. Mayer, K. Jensen

31. 31 TM© T. Mayer, K. Jensen

32. 32 STONECREST MEDICAL CENTER 47K Annual ED Visits Before and After EBM Guidelines Decreased “ER boarding time” by over 2.50 hours BEFORE Rapid Admission Process ED >3.5 Hours (210 minutes) Floor AFTER Rapid Admission Process ED Floor <45 Minutes TM© T. Mayer, K. Jensen

33. 33 Many units/departments attempt to optimize patient flow  Sub-optimizing flow in other areas  Sub-optimizing flow throughout the entire acute care system Flow As a System KJ© T. Mayer, K. Jensen

34. 34 This Is Not Your Typical Hospital-Wide Bed Meeting  Predicts capacity  Predicts demand  Documents a plan if demand is predicted to be greater than capacity  Evaluates the success or failure of predictions and plans  Uses failures and successes of predictions and plans to develop the key improvement projects to improve flow KJ© T. Mayer, K. Jensen Hospitals require an administrative system for flow that at the unit level:

35. 35 Unoccupied time feels longer than occupied time TVs, magazines, health care material Company-friends and family ROS forms, kiosk, pre-work Frequent” touches” Pre-process waits feel longer than in-process waits Immediate bedding No triage AT/AI (Advanced Treatment/Advanced Initiatives) Team Triage Anxiety makes waits seem longer Making the Customer Service Dx and Rx Address the obvious-pre-thought out and sincerely deployed scripts Patient and Leadership Rounding Uncertain waits are longer than known, finite waits Previews of what to expect Expectation Creation Green-Yellow-Red grading and information system Traumas, CPRs-Informed delays Patient and Leadership Rounding Unexplained waits are longer than explained waits In-process preview and review Family and friends Patient and Leadership Rounding Unfair waits are longer than equitable waits Announce Codes Fast Track Criteria known and transparent The more valuable the service, the longer the customer will wait The Value Equation -Maximize benefits for the patient and significant others + Eliminate burdens for the patien and significant others Solo waits feel longer than group waits Visitor Policy-The Deputy Sheriff takes a furlough Managing the family’s expectations It’s OK to leave for awhile On-stage/Offstage Putting the Psychology of Waiting to Work KJ© T. Mayer, K. Jensen

36. 36 516 Million Specialist Visits Taking people out of their comfort zones Finding flow requires… Finding Flow Asking “Why” and “Why Not?” Incessantly Getting them with you on the takeoff Creating hope… KJ© T. Mayer, K. Jensen

37. 37 Patient Arrival in ED EM Physician work up EM calls HM Physician HM Assumes Care Patient Admitted Parallel Processes Improve Flow Before: Sequential Processing KJ© T. Mayer, K. Jensen

38. 38 Start Patient Arrival in ED EBM Work-Up (EM=HM) EM-HM Collaborate HM Assumes Care Patient Admitted Parallel Processes Improve Flow After: Parallel Processing KJ© T. Mayer, K. Jensen

39. 39  Move the entire curve  Where do you spend your time? Hint: 80/20  Decrease variation that doesn’t add value Changing the Culture TM© T. Mayer, K. Jensen

40. 40 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… © T. Mayer, K. Jensen

42. 42 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. © T. Mayer, K. Jensen

43. 43 • 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. © T. Mayer, K. Jensen References

44. 44 • 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. © T. Mayer, K. Jensen References

45. 45 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. © T. Mayer, K. Jensen

46. 46 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. © T. Mayer, K. Jensen

47. 47 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. • 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. • 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. • 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. 47 © T. Mayer, K. Jensen

48. 48 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 book- www.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. © T. Mayer, K. Jensen