Hardwiring Hospital-Wide Flow To Drive Competitive Performance

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

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

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
Shared Mental Models
Aligned Strategic Incentives
Rule #1, Rule #2…
PATIENT
Healthcare
Environment
Team
Hospital
Medicine
Ourselves

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

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

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

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

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)

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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

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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

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?

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?

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

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.

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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-

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

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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

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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?

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

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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...
Thom Mayer/Kirk Jensen - Hardwiring Flow

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

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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

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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!

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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
Keep Vertical Patients Vertical-and Moving!

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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

ACCELERATING FLOW
INTO YOUR HOSPITAL

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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

PARTNERING WITH
HOSPITAL MEDICINE

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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

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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

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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

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
Hospitals require an
administrative system for flow
that at the unit level:

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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
Unexplained waits are longer than explained waits
In-process preview and review
Family and friends
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

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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…

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

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

39
 Move the entire curve
 Where do you spend your time? Hint: 80/20
 Decrease variation that doesn’t add value
Changing the Culture

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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…

41
Flow Resources

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.
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Care, Better Health, and Lower Costs. San Francisco, CA, John Wiley & Sons: 2012.
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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.

43
• Cottington, S, Forst, S. Lean Healthcare: Get Your Facility into Shape. Marblehead, MA, HCPro:
2010.
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Press: 2011.
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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
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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
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Books: 2009.
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• 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

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.
References

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.

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.

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

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.

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