This document summarizes a presentation given by Jeff Ward from Lee Memorial Health System about improving patient flow and addressing nurse staffing issues. The presentation discusses using data to identify opportunities to reduce emergency department length of stay and the number of patients leaving without treatment, which could yield millions in additional revenue. It also covers how the health system became a preferred employer through programs that improve nursing productivity, retention and recruitment in order to address the industry-wide nurse shortage. The presentation concludes with a Q&A section.

1. © 2005, Dimensional Insight, Inc.
Patient Flow Woe
and
The Too Few Nurse Curse
Jeff Ward,
Lee Memorial Health System
See us at
Booth# 6741

2. © 2005, Dimensional Insight, Inc.
Agenda
• Why?
• Why Me!
• Patient Flow: From Woe to Woo-Hoo
• Too Few Nurse Curse: From Few to Phew
• The Next Step of the Journey
• Q&A

3. © 2005, Dimensional Insight, Inc.
Why?
• Lee Memorial Health System
– A Not-For-Profit Corporation in Southwest
Florida.
– Comprised of 3 Acute Care Hospitals and
Multiple Other Facilities
– More than 6,200 Employees

4. © 2005, Dimensional Insight, Inc.
Why?
• 3 Unique Demographic Challenges
– One of the Fastest Growing Metros*
– Way Too Much Sunshine!
(Population Almost Doubles during Winter Months)
– Increasing Fraction Dependent on
Medicare, Medicaid and Charity Care
* Forecast magazine lists Fort Myers-Cape Coral 15th in its "Booming 25" ranking of the 25 fastest growing metro areas through the year 2005.

5. © 2005, Dimensional Insight, Inc.
Why Me!
• In Healthcare IT Since 1985
• 14 Years at Lee Memorial
• Oversight of Business
Applications
• Helped Get Our Data Out of
Jail…

6. © 2005, Dimensional Insight, Inc.
Patient Flow Woe
• A Busier ED, and yet…
• Good Data is the Key
• Insights Lead to Opportunities
• Opportunities Come in All Sizes…
– The $3m Opportunity
– The $1m Opportunity
– The $12m Opportunity

7. © 2005, Dimensional Insight, Inc.
Volume
Continues
to Grow…
ED Patient Volume (2004)
2000
2500
3000
3500
4000
4500
JA
NUA
RY
FEBRU
AR
Y
M
AR
CH
APRIL
M
AY
JU
NE
JU
LY
AU
G
UST
SEPTEM
BER
O
C
TO
BER
NO
VEM
BER
DECEM
BER
Lee Memorial Hospital Cape Coral Hospital HealthPark Medical Center

8. © 2005, Dimensional Insight, Inc.
But ED Becomes
the Doctor’s
Office! ED Admits as Percentage of ED Volume
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
22.0%
24.0%
26.0%
JAN
U
AR
Y
FEB
R
UA
RY
M
A
RC
H
A
PR
IL
M
A
Y
JUN
E
JULY
A
UG
USTSEPTEM
BER
O
C
TO
B
ER
N
O
VEM
BER
D
EC
EM
BER
Lee Memorial Hospital Cape Coral Hospital HealthPark Medical Center
Admit Rate is 80th Percentile*
* The Advisory Board, 2003 Data

9. © 2005, Dimensional Insight, Inc.
…and Market
Share
Falls
67.1
65.1
63.0
57.9 57.1
54.9
ED Pediatric ED
Lee Memorial Health System ED Market Share (%)
2002 2003 2004

10. © 2005, Dimensional Insight, Inc.
ED Patient Flow
Goals
• Length of Stay 15-25%
• Patients that Leave Without
Treatment 20%
• “Arrival” to “Seen by Physician” Time 15%
• Time from “Decision to Admit” to
“Inpatient Bed” 20%
• Wasted ED Bed Capacity 15%
• Utilization of Fast Track 30%
• Bed Turns 15%
• Productivity per Patient 15%
• Key Press Ganey Measures 83.5%
Decrease Increase

11. © 2005, Dimensional Insight, Inc.
Fast Track is…
• Nurse Assesses whether to “Fast Track” Patient
– Eg. Patient Could Visit Doctor’s Office, or Condition is Not Life/Limb
Threatening
• Fast Track Patients Treated by Mid-Level Practitioner under
Direction of ED Physician
– RN & Technician Give Treatments, Discharge Instructions etc.
• When Fast Track is Closed, Fast Track Candidates
– Are Treated in Regular ED by ED Physician or Mid-Level
Practitioner
– Have Lower Priority
– May have Other Patients Pulled Ahead of them

12. © 2005, Dimensional Insight, Inc.
Our Process
Improvement
Approach
• Drive Process Improvement via Small
Cycles of Change
– Try Something for a Shift, a Day, a Week…
– Measure the Impact
– Tweak, Rollout, or Re-Think as Appropriate
• Previously used this approach to
– Cut ED Divert from 500 Hours a Month to Zero
– Cut ED-to-IP Bed Turnaround Time by 10 Hours
– Improve ED Triage Time by 3 Hours

13. © 2005, Dimensional Insight, Inc.
Initial Focus:
ED Waiting
Room
Fill-Out
Pre-Reg
Slip
Pre-Reg Triage
Range 3-13 Min. Range
2-90 Min.
Range 3–140 Min.Range
4-34 Min.
Waiting
Waiting for
Transfer to Back
Average
2 Min.
+/- 3 Min. Average
27 Min.
Average
11.5 Min.
Average
39 Min.

14. © 2005, Dimensional Insight, Inc.
A Real Patient
Flow Example
• Initially, Open Beds in ED
• Patient Fills Out “White Slip” Prior to Registration
• No-One at Registration Desk…
– Patient Waits 8 Minutes before being Registered
• Waited 2 Minutes for Triage Nurse
– Triage took 14 minutes
• Patient went back to Lobby via Wheelchair
– Now, 9 Open Beds in ED
• Patient Taken to ED Bed after 21 Minute Wait
43 Minutes Total to ED Bed

15. © 2005, Dimensional Insight, Inc.
The Opportunity :
LWOTS
ED Visitors Leaving Without Treatment (%)
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
January
February
M
arch
A
pril
M
ay
June
July
A
ugust
Septem
ber
O
ctober
N
ovem
ber
D
ecem
ber
Lee Memorial Hospital Cape Coral Hospital HealthPark Medical Center
National Average LWOTS = 2.5%1
1 The Advisory Board, 2003 Data

16. © 2005, Dimensional Insight, Inc.
The Opportunity :
$3m
ED Patients Leaving Without Treatment: 6492
Average ED Charge($): $225
Lost ED Revenue: $1.5m
Lost Admits (5% of LWOTS): 324
Average Revenue for ED Admit($): $6265
Lost IP Revenue: $2.0m
Total Revenue Opportunity: $3.5m

17. © 2005, Dimensional Insight, Inc.
Good Data is
The Key
7.3% 8.2%
30.4%
Lee Memorial Hospital Cape Coral Hospital HealthPark Medical
Center
Missing Dispositions

18. © 2005, Dimensional Insight, Inc.
Congestion
Builds
During
The
Day
Time to Disposition (Mins.)
0
50
100
150
200
250
300
350
400
Patients Ordered by Time to Room
Early AM Late PM
Moving Average Disposition Time

19. © 2005, Dimensional Insight, Inc.
Mirrored by
ED Length
of Stay
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
1
A
M
-5
AM
7
A
M
-9
AM
9
A
M
-11
AM
11
A
M
-1
PM
2
PM
-4
PM
4
PM
-6
PM
6
PM
-8
PM
10
PM
-12
AM
ED Length of Stay by Arrival Time (Hours)

20. © 2005, Dimensional Insight, Inc.
The Opportunity :
Wasted Bed
Hours
9070
4759
23736
0
5000
10000
15000
20000
25000
Lee Memorial Hospital Cape Coral Hospital HealthPark Medical
Center
Wasted Bed Hours*
* Total Holding Time, Less 1 Hour per Patient
7.8% of System-wide Bed Hours
Are Holding Admits (Past 1 Hour)

21. © 2005, Dimensional Insight, Inc.
The Opportunity :
$1m…
Wasted Bed Hours per Month: 1333
Assume 75% Probability to Pull Patient: 1000
Bed Turnover per Hour: 0.1
No. of Potential Patients 100
Average ED Charge($): $225
Cost of ED Holds $22,500
Repeat with Real Data, 3 Hospitals x 12 Months…
Total Revenue Opportunity: $1.2m
Using Dummy Data to Keep the Math Easy…

22. © 2005, Dimensional Insight, Inc.
The Opportunity:
$12m
0.00
1.98
4.12
6.47
9.03
11.85
0 4 8 12 16 20
ED Length of Stay Reduction (%)
Length of Stay: Additional Revenue Potential ($m)
Based on: Lee Memorial Health System LOS = 300 Min.
National Average LOS* = 147 Min.
Best Practice LOS* = 91 Min.
National Average ED Revenue/Visit* = $ 225
National Average Revenue via ED Admission* = $6,778
* The Advisory Board, 2003 Data

23. © 2005, Dimensional Insight, Inc.
Too Few Nurse
Curse
• Dealing With Industry-wide Skills
Shortage
– Become a Preferred Employer
– Focus on Nursing Productivity
– Data-Driven Retention & Recruitment
• Opportunities Come in All Sizes…

24. © 2005, Dimensional Insight, Inc.
A Preferred
Employer
• Premier Workplaces: One of Ten “Premier
Employers in Healthcare”1
– “Best in Class" for Outstanding People Practices and HR
Programs that Attract and Retain Diverse Talent
– Reviewed Categories such as Compensation, Benefits, Diversity
Strategies, Learning and Development, Work/Life Balance, and
Culture and Values
• Herman Group: One of Four “Employer of Choice”
Awards in Healthcare2
– “Employers of Choice, such as Lee Memorial Health System, who
are able to attract, optimize, and retain top talent, will enjoy a
substantial tactical advantage over their competitors”
-- Roger Herman, CEO of Employer of Choice, Inc.
1 Premier Workplaces, a national, independent, benchmarking organization, 2005
2 Herman Group, 2003

25. © 2005, Dimensional Insight, Inc.
Making Timely
Staffing
Decisions
• Staffing & ADT Info is Automatically
Integrated in “near Real-Time”
• Dynamic Decision Making on
Nursing Skills Needed to Care for
Current Patient Census
• Eliminate “Un-necessary” Overtime
and Travelers thru Better, More
Timely Decisions

26. © 2005, Dimensional Insight, Inc.
Improving
Retention and
Recruiting
• Retained Additional 200 Staff
• $42k to Replace Nurse1
$8.4m Saved
20%
14%
Staff Employed Less Than 90 Days
1998 2003
53%
65%
Staff Remaining Employed After 1 Year
1998 2002
1 Estimated cost of replacing medical/surgical nurse,
Advisory Board Company for Nursing Executive Center, 2000.

27. © 2005, Dimensional Insight, Inc.
Improving
Retention and
Recruiting
• Track
– KIWI (Key Information &
Workforce Indicators) trends
including turnover, hiring,
terminations.
– Track JCAHO Compliance for HR
data
• Easily Segregate Employee
Population by Age, Length of
Service, Direct Patient Care, VP
etc.
– Eg. Average Age is 44.5 and
Length of Service is 6.11 Years
7.8%
6.8%
Voluntary Staff Turnover
2003 2004

28. © 2005, Dimensional Insight, Inc.
Q&A
See us at
Booth# 6741