12 missildine-choc-improving throughput


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12 missildine-choc-improving throughput

  1. 1. Improving a Mission-Critical Cross-FunctionalMeasureTHE ACTIVESTRATEGY CONFERENCEAPRIL, 2012CHERYLCHERYLCHERYLCHERYL MISSILDINEMISSILDINEMISSILDINEMISSILDINE, MSN, RN, NEA, MSN, RN, NEA, MSN, RN, NEA, MSN, RN, NEA----BCBCBCBCCHOC CHILDREN’S HOSPITALORANGE, CASession ObjectivesThe attendee will:• Describe how the alignment of strategic initiatives drivesprocess and practice changes to sustain results.• Describe how systems theory was utilized to redesign thecare delivery models to improve patient throughputstructure, processes and outcomes.• Discuss the use of technology to embed structure andprocess in support of patient throughput practices.• Explain how technology was designed to abstractevidenced-based performance improvement metrics andsystematically disseminate information across theorganization.
  2. 2. CHOC Children’s Hospital(Orange, California)FY 2011 – Hospital Statistics• 238 Inpatient Beds• ED Visits 54,553• 11,811 Admissions• 5.0 Average LOS• 81,713 Primary Clinic Visits• 86,035 Specialty Clinic Visits• 4,001 Transports3CHOC Children’s Hospital - Mission
  3. 3. Patient Flow and Throughput: A National CrisisChild Health Corporation of America (2009); Patient Flow and ThroughputPediatric hospitals face:• Steady increases in patient volumes• 46% Admission from Emergency Department (CHOC 65% ED origin)• Competition for available beds• Sources not aligned with one another• Inefficient processes− Bed Assignment− Discharge− Bed Turnover• 67-98% occupancy ratesOrganization Wide Strategic Initiative6
  4. 4. Data Used to Select the Project• Executive Management Team and the Quality OversightCommittee, Joint Leadership Committee (JLC) received thefollowing concerning data:− ED Data demonstrated lower volumes and longer wait times forpediatric vs. adult patients.− Admission demands peaked prior to patients discharge times resultingin delays− Admissions cancellations occurred related to capacity− Hospital occupancy (73%) was in the lower quartile compared toother pediatric hospitals in a collaborative comparison group7Identified Potential Stakeholders• External Stakeholders− Patients/Families− Community MDs− Referring Community/RegionalHospitals− Clinics− ED Physicians− Hospitalists/Surgeons• Internal Stakeholders− Admitting Department− Medical Residents− Nursing Supervisors− Transport Team− Nursing Units− Case Managers− Pharmacy− Interpreters/Translators− Environmental Services− Quality− Informaticist (TechnologicalSupport)8
  5. 5. Organizational Goals and Mission• CHOC Children’s Strategic Goals with Metrics− Operations and Infrastructure (High Impact)▪ Admission Volumes/Average wait time▪ Time from order to discharge▪ Bed turnaround time− Clinical Quality, Safety, and Service (High Impact)▪ Emergency Department Scorecard− Growth and Development (High Impact)▪ Average daily census− Financial Stewardship (Medium Impact)▪ Increased admissions, enhanced efficiencies, and decreasecancellations− Partnerships and Affiliations (Medium Impact)▪ Successful affiliations10
  6. 6. InterdisciplinaryPerformance Improvement Team11Uniting people:Patient Throughput – The PlanGoals− Promote patient safety by ensuring timely, appropriateinpatient admissions− Implement strategies to facilitate bed supply anddemand throughout the day− Provide hospital services and infrastructure to supportefficient patient care to create “virtual bed capacity”Initial Strategy− Formal Improving Organizational Performance (IOP)Committee12
  7. 7. The Patient Flow Improvement TeamInterdisciplinary Team(Care/Support Services)• Nursing Director, ED• Manager, Admitting• Director, Case Management• Admissions/Nursing Supervisor• Nursing Director, Med/Surg• Nursing Director, PICU• Manager, PI• Director, EVS• Transport Team• PACU Manager• Exec. Director Lab/Imaging• Manager, OP PharmacyInterdisciplinary Team, cont.• CHOC at Mission, RN Manager• Nursing Informaticist• Exec. Director, PatientAccess/ThroughputMedical Staff Members(Internal/External Customers)• Physician Champion• ED Medical Director• Director of Pediatric Residency• Medical Director of PatientSafety and Quality• Chief Residents• Hospitalists13Uniting people:Overall Team StrategiesLink to organizational Strategic PlanInterdisciplinary shared goalsImprovements based on evidenceHardwiring of budget-neutral structureInteroperability of Electronic Medical RecordElectronic Throughput Balanced Scorecard14
  8. 8. SystemEvaluationDelays inAdmissionsPERFOMANCEPLANCareACT service DOOutcomeCHECKEVSDepartmentServicesStandardized, timelyRoom cleanEVSDepartmentServicesBed Turnaround<60 minutesSystemOutcomesIncreaseCapacityPurposeGoalsExpectationsWorkplacequalityLeadershipServicequalityResourcesSYSTEMS DYNAMIC: FROM STRATEGY TO GOAL ACHIEVEMENTExcerpt from: The Quantum Leader. Kathy Malloch, Tim Porter-OGrady 2009Red Flags “Issues” in Patient Throughput (as of 6/2007)(Advisory Board, 2002: Maximizing Hospital Capacity)
  9. 9. Throughput Process - PhasesPre-admissionAdmissionCare DeliveryDischargePlanningDischargeBed TurnoverFinal Root CausesPre-admissionAdmissionCare DeliveryDischargePlanningDischargeBed TurnoverNo single point of entryLack of standardizedadmission processesUnaware of bedavailabilityStaffing Model to supportdemandManual Data ProcessStaffing model for CaseManagementRN Staffing did notsupport unitdemand/turbulenceManual data processDelays waiting fordischarge medicationsDelays waiting fortranslationDischarge notificationdelaysLate peak discharge timesVariable clinicianperformance in throughputdischarge processesManual notification BedTurnover ProcessMultiple bed coordinationefforts.18
  10. 10. Patient Flow Improvement Team – “Green Flags”(Advisory Board, 2002: Maximizing Hospital Capacity)Red Flags (Issues) in Patient ThroughputChanging Practice Culture –Individual Processes• Key stakeholders (front-line staff) participate (PLAN)• Conduct a “Walk in my shoes” assessment (PLAN)• Current process documented/flow chart (PLAN)• Current facilitators/barriers identified (PLAN)• Brainstorming practice/electronic solutions (PLAN)• Brainstorming metrics for documented desired results (PLAN)• Rapid Improvement Events – PDCA (DO)• Electronic solution reports created (DO)• Measurement occurs (CHECK)• Refine process to achieve/sustain results (ACT)
  11. 11. Stakeholder Involvement in ImplementationReference: Institute for Health Care Improvementhttp://www.ihi.org/IHI/Topics/Improvement/SpreadingChanges/21Improving ThroughputUniting People, Process andTechnology22Pre-admissionAdmission
  12. 12. Solutions ImplementedPre-admissionAdmissionCare DeliveryDischargePlanningDischargeBed TurnoverElectronic Bed BoardComputerized providerorder Entry (CPOE)Standardized AdmissionsprocessesPatient Placement CenterDedicated TransporterDedicated RNElectronic dataabstraction23•Establishing Structure and Process: Pre-admission/Admission:Technology Solutions – The Electronic Bed BoardBed Board - Live since February 2007− Includes data required to cohort patients andmeasure outcomes− Tracks pending and actual admissions,discharges and transfers− One view of entire hospital’s beds and theirstatus− Links to Computerized Provider Order Entry(CPOE)− Linked to EVS Dispatch and Tracking Software24
  13. 13. Establishing Structure: Pre-admission/Admission:Electronic Bed Board – Admission ActivityEstablishing Structure: Pre-admission/Admission:Electronic Bed Board –Discharge Activity
  14. 14. 27Establishing Structure: Pre-admission/Admission:The Patient Placement Center
  15. 15. Automated Reporting29Improving ThroughputUniting People, Process andTechnology30Care DeliveryDischarge Planning
  16. 16. Solutions ImplementedPre-admissionAdmissionCare DeliveryDischargePlanningDischargeBed TurnoverStaffing Model –-Charge RN,-Flex RNs- Case Managers,Work flow processesDischarge Planning-Pharmacy-TranslationAuto text paging –TranslatorsAuto Translation-SpanishDischarge Instructions31Establishing Structure and Process: Care Delivery/Discharge Planning:Nursing Strategies• Defining the Medical/Surgical Specialty− Get them in, get them better, get them home !• Flex RN− Peak turbulence hours• Increased charge RN 1:24 beds - (throughput one of theirmain roles)− Perceived acuity was actually chaos• Discharge Predictions• Hospitality Escorts• Re-alignment of Nursing Case Management Model
  17. 17. Establishing Structure and Process: Care Delivery/Discharge Planning:Discharge Planning Technology Solutions•Discharge Assessment on Admission•Discharge KardexDischarge Interdisciplinary RecommendationsDischarge Provider “Arrange For” OrdersCase Management Arrangements•Provider Discharge Order•Discharge Instructions•Pediatric Electronic Patient Education•Pediatric Formulary including Patient Education ToolsDischarge Technology – The Discharge Kardex
  18. 18. Establishing Structure and Process: Care Delivery/Discharge Planning:Interpretation Workflow and Technology SolutionsInterfaced to CPOE and Clinical DocumentationDecentralized Interpreter “office” to high utilizationlocationsAutomated workflow processesDischarge Instructions marked by nurse as ready fortranslation and patients prefers information in Spanish,System pages appropriate translator “Dischargeinstructions ready for translation, room 422 bed 1”35Physician Discharge Summary
  19. 19. Spanish Translation of Discharge InstructionsImproving ThroughputUniting People, Process andTechnology38Discharge andBed Turnover
  20. 20. Solutions ImplementedPre-admissionAdmissionCare DeliveryDischargePlanningDischargeBed TurnoverDischarge PredictionElectronic White BoardReal-time notification ofdischargeAuto-texting paging – EVSEVS bed turnover softwareElectronic Abstraction ofData39Establishing Structure and Process: Discharge/Bed TurnoverKey Strategies and Technology SolutionsNursing/Physician Residents collaborate to predictdischarges at 3:00amDischarge predictions and orders populate an electronic“White Board” in the nursing unitsDischarge Orders “auto populate” the “White Board”Hospitality Escorts communicate “real time” discharge tounit secretary who enters discharge into the computer.Automatic text page is sent to the EVS associateresponsible to clean the room.EVS bed turnover process is viewable in the PatientPlacement Center40
  21. 21. Establishing Structure and Process: Discharge/Bed Turnover:Electronic White BoardData Drives Outcomes and InspiresImprovementData Data Data
  22. 22. System for Measuring/Sustaining Results4344Since the PPC Implementation in July 2008, CHOC ED admits volume is significantly increased, whilethe call to arrival time is significantly decreased. Average monthly ED admission volumes haveincreased from 366 (FY2008) to 466 (FY2011) which represents a 27% increase, while the average callto arrival time has decreased from 3.36 hours (FY2008) to 2.81 hours (FY2011) which represents a 16%decrease. Above is a chart from ActiveStrategy that we use to track this measure on a monthly basis.PPC Implemented in July 2008
  23. 23. 45Since the PPC Implementation in July 2008, average external monthly ED admission volumeshave decreased from 375 (FY2008) to 362 (FY2011) which represents a 3% decrease and theaverage call to arrival time has decreased significantly from 3.42 hours (FY2008) to 2.76 hours(FY2011) which represents a 19% decrease. Above is a chart from ActiveStrategy that we use totrack this measure on a monthly basis.PPC Implemented in July 200846Since the PPC Implementation in July 2008, Controllable Cancellations is significantly decreased.Total Number of Controllable Cancellations has decreased from 281 (FY2008) to 54 (FY2011) whichrepresents a 81% decrease. Above is a chart from ActiveStrategy that we use to track this measureon a monthly basis.PPC Implemented in July 2008
  24. 24. 47Since the PPC Implementation in July 2008, time from discharge order written to actualdischarge is significantly decreased. Average time has decreased from 165 mins (FY2008) to120 mins (FY2011) which represents a 27% decrease. Above is a chart from ActiveStrategythat we use to track this measure on a monthly basis.PPC Implemented in July 200848Since the PPC Implementation in July 2008, Actual Discharge to Charted Discharge for the Med Surg4th is significantly decreased. Average time has decreased from 0.49 hours (FY2008) to 0.12 hours(FY2011) which represents a 76% decrease. Above is a chart from ActiveStrategy that we use totrack this measure on a monthly basis.PPC Implemented in July 2008
  25. 25. Since the PPC Implementation in July 2008, Actual Discharge to Charted Discharge for the Med Surg5th is significantly decreased. Average time has decreased from 0.61 hours (FY2008) to 0.12 hours(FY2011) which represents a 80% decrease. Above is a chart from ActiveStrategy that we use totrack this measure on a monthly basis.PPC Implemented in July 2008CHOC in 2013 – Shared Services Onbarding• Surgical Services• Laboratory Services• Imaging Services• Emergency Services• Additional BedsGOAL: INTEROPERABILITY BETWEEN NEW ANDEXISTING SYSTEMS.
  26. 26. Questions?