Reimbursement: Trends & Strategies in Emergency Medicine May 18-20, 2015 Ft. Lauderdale, FL

Transcription

1 (+) James J. Augustine, MD, FACEP Reimbursement: Trends & Strategies in Emergency Medicine May 18-20, 2015 Ft. Lauderdale, FL Maximizing Patient Throughput to Improve Productivity and Increase Revenue Vice President, Emergency Department Benchmarking Alliance (EDBA); Clinical Associate Professor, Department of Emergency Medicine, Wright State University, Dayton, Ohio; Director of Clinical Operations, EMP, Past Chair for the Joint Commission Hospital Professional Technical Advisory Committee, and on the Board of Commissioners. In his 31 years of service in Emergency Medicine and EMS, has served as a Medical Director in Washington, DC, Atlanta, GA, and Dayton, OH. National consultant, author, and speaker related to emergency department operations, design, and preparedness. Discuss key drivers of patient thoughtput Identify strategies to monitor, report, and improve throughput Describe the revenue impact of enhanced department productivity 5/19/2015 9:30:00 AM-10:30:00 AM Panorama A,B TU-9 DISCLOSURES: (+) No significant financial relationships to disclose

2 Maximizing Patient Throughput to Improve Productivity & Increase Revenue James J. Augustine, MD Director of Clinical Operations, EMP Board of Directors, ACEP The Value of Emergency Care In the House of Medicine To Primary Care To the Specialists To the Community To the Payors The Call for Transparency Time of Care Safety and Quality ED Pt Experience of Care Survey Cost and VALUE 1

3 The Clockwork ED Where are we: TJC And CMS CMS Hospital Inpatient Quality Measure, the Boarding Time measure Admit Decision to Departure Time Time Interval beginning when Admit Decision is made until the Admit Decision actual departure time of the patient from the ED This is a softball to help us get traction on Boarding Time They are Trying to Help Us! ED Presentation Departure to Inpatient Unit 2

4 This is what Throughput Looks Like, and is Composed of Service Goal 100 mins 100 Minute Door to Door Intake Process 10 mins Through Time 70 mins Disposition Process 20 mins Greeting Registration ED Bedflow Diagnostics Therapeutics Admit Discharge Transfer Triage When Needed Bedside Tracking System X-ray Lab Respi- Ratory Therapy Hospital Bed Mgt Financial Counseling Transportation Equipment Process Major IS Application Nursing Push or Pull? Drawing? ED Doc Med Staff Radiology Path Gen Med Staff Ancillaries Registration IS RT, Soc Svc Admissions Finance EMS Clerk Tech Transport? itional Nurse Triage 3

5 Traditional ED Greeting T H E Help Me!! Patient Enters the ED Clerk Greeting Go Sit Nurse Triage Go Sit W A L Room Assignment Chart in Rack Doctor L Message = Time = Finances First 5-20 mins This is my caretaker, Right? 5-20 mins Why am I Waiting? Push or Pull System? Unknown time Unknown time How much do People like it Out Front? Ebola???? Not!! 4

6 Pull till Full The Patients Have Told us it is about: Time to Provider Intake: Critical Care Patient 5

7 Model for Intake: The Critical Patient Simultaneous Bedside Intake, Reg, and Evaluation Intense Diagnostics and Therapeutics DISPOSITION Ancillaries to bedside Another Perspective on Flow Why Doesn t L&D have Delivery in the Hallway? A Diversion Policy? Moving Patients Between Beds? Walkaways? A Big Waiting Room? Is L&D not the other Front Door to the hospital? Why don t they have to do what the ED has been designed to do? 6

8 The Intake Failure: How Did we Get Here? Belief that Patients and families Belong out Front Belief in Clerk Screening Belief that it has to be done, by Nursing Believe Walkaways are a good idea, are low acuity, and save time for doc Is it Greeting, or Intake, or Triage? Downside of Poor Flow Walkaways Death in the Waiting Room Was Civil Matter (Malpractice) In 2007 became Criminal 7

9 Triage Did a Lot of Work on Protocols Nurse Pushback and Inconsistency Licensing Issues TJC Pushback Physician As Greeter Patient Intake Area (Push System) Doctor Specifies: Vertical or Horizontal STRETCHER CHAIR ROOM Registrar, Nurse Physician Some patients discharged directly DISPOSITION Doc or APP in back 8

10 What About a Doctor in Greeting Area? That is what they do in other countries Models of success now published Reduce Walkaway Initiate Evaluation and Diagnostics Improve STAFF and Patient Satisfaction Why Physician Intake? Assign right patient to right resources at the right time Get EMS Back on the Street Initiate certain Diagnostic Process (EKG, CT, contrast) Start Treatment! Facilitates work of the physicians and APPs Where is my Dad? 9

11 /6/2015 EDs have a Predictable Arrival Pattern EUH S Fulton CLH MGH Arrivals Per Hour Sweet spot for Physician First Patient Arriv :00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 Hour of Day 18:00 20:00 22:00 EUH CLH SFMC MGH MVH CCED GSH FF SRMC TTH WBH MRH SRMC 02 Gaston Pinnacle 10

12 Impact: Reducing Time to Doc Acuity Time Patient Experience Minor Little No Change Medium Major Major Staff Satisfaction: Improved when Team is Empowered to Develop and Implement Serious Major Little Critical No No Change Greeting will be Different in the ED Volume Bands There is a Sweet Spot in Here 11

13 Messing with the Triage Process Can it be Negotiated with among the docs Integrate with Nursing? Integrate with Registration? Impact on Throughput People quit dying in the Waiting Room Decrease in LBTC => volume increase Revenues and Pt Experience enhanced Work out doc productivity issue EMP of Hamilton Doesn t Mesh Well with a Certain New ED EHRs (Not that cases revolve around ED docs and nurses seeing the same intake info and vital signs!) Reduce Collapses in Waiting Room Reduce LBTC, and community lore Reduce LOS, all measures The Flow Doctor sees all incoming patients except Critical Care. Moves with computer 12

14 When Implemented as a Team All sites had Similar Impact on ED Performance Measures Improved throughput Improved walkaway rates Improved satisfaction (patients, docs, staff) Enhanced volume Enhanced revenues Decrease risk Decrease negative media stories Relating Good Greeting Practice to Patients The Front Door function Matches need for a positive First Impression Wayfinding and security elements Matching patients with reservations Reducing time to EMS patients Reduce collapses in the waiting room Reduces acting out and gives Flow Doctor a great look at patients as they walk in 13

15 HOW TO: Building a Best Practice in Time to Provider Agree with all elements that it is nonproductive, adds work, antagonizes patients, and is negative for patients and visitors It decreases revenue and increases costs Staff don t like it, and antagonize each other SO: Build a Hospital Front End Design Team Build a team to refresh the ED Greeting Process (High Impact Team) Define the necessary elements for the ED Building an Innovative Model The Flow Doctor Flow Diagram Cannot be Done in Single Model HOW TO: FLOW CHART Experience Indicates Three Levels of ED Activity Not busy Steady State Very busy 14

16 Building a Best Flow Practice Find a Time to do Rapid Cycle Test (Not busy days) Implement the process for an appropriate time or group of patients and get feedback (Rapid Cycle Testing) Find Problems Correct them Cycle on Flowcharting the Intake Process Setting 1 Open Beds, Slow Setting 2 Steady State Setting 3 No Beds, Fast Pace 15

17 ED Activity Setting 1 Door Multiple rooms open Comfortably Busy No wait time Bed ED Activity Setting 2 Doors Process, Orders Steady State Most rooms are filled, but Rooms are opening on a regular basis EMS patients are being moved promptly Beds 16

18 ED Activity Setting 3 Traffic Control, Triage, Treat in Greeting Area Very busy Every room is filled Likely have admitted patients boarding in ED Flow Doctor managing more patients in the front area The Role of the Flow Doctor Greets all patients that are arriving ambulatory Greets all EMS arriving patients that are not critical enough to require immediate care by a physician in the critical care area Assigns priorities for care for all patients, and that is determinant of order of care, followed by the order of arrival Cooperates with greeting staff to get patient registered quickly Performs a rapid history and physical Initiates diagnostics for arriving patients Initiates treatment and therapy for arriving patients Insures each arriving patient knows that he/she has been seen by a doctor Places in or removes patients from long backboards and/or packaging Takes phone calls from physicians/clinics on incoming patients Places notes appropriate for the triage function, in the correct area of the medical record Does supervisory notes for any patients seen with mid-level providers Place timely medical staff notification for immediate care (FB impaction, STEMI, Stroke) Collaborate with Charge Nurse in broadcasting the level of activity to ED staff Where needed, oversee the midlevel providers Treat and discharge a few patients from the Greeting Area, and do their complete medical record 17

19 Service Industry Models of Flow Consumer Flows The License Bureau Medicaid Office INTAKE PROCESS EXIT Get Me Out Of Here!! Department Store Hotel 18

20 Funnel Options For The ED The Typical ED The Constipated ED The Turnstile ED The Open ED ED INTAKE WORKUP DISCHARGE Get Me Out Of Here!! Pay Arrangements As You Leave Improving Greeting Performance Important at all Three Flow Levels The CUSTOMETER Horizontal = vertical Patient = customer Design the facility to accommodate more upright patients 19

21 The Vertical Patient Vertical = CUSTOMER = CHAIR Study shows Patients prefer chairs to gurneys The Horizontal Patient Horizontal = PATIENT = STRETCHER & ROOM 20

22 Design for Flow Concepts Flow Doctor at appropriate times of day reduces need for beds or chairs. That doctor is mobile (DO NOT create a single room) Opens the Front End Families move to bedside Add patient chairs as efficient care space Subwaiting rooms in back for pt and family Universal Room Design with Open Flow Front End Procedure Room IVs, Labs Sniff Analyzer To ED The Discharge Room Security The Chutes In 21

23 This image cannot currently be displayed. This image cannot currently be displayed. This image cannot currently be displayed. 5/6/2015 Building the Better Greet Process HOW TO: Team elements: Nurses, Clerks, Techs, Docs, Security Front End Design Team Is the Physical Space Compatible? Update IS Design: Quick Reg Paperwork, quick order pages, and the IT system (WOWs work great) Supplies (Urine cups. ) Intake System Design Call in by patient or PCP to doc greeter Patient Care Area Work Up Initiated Register We heard you were coming! DISPOSITION 22

24 Intake System Design Kiosk or itriage Sign In Intake Flow Doctor Plug In Patient Care Area Work Up Kiosk for Disposition The Greeting Process (Future) Allows Triage out Drives surveillance system Assign workload expected for patient The Flow Doctor sees all incoming patients Apply EMS patients to the system 23

25 ED Disposition Treat and Release ED-based CDU To Jail/Nursing Home/ Admit/Observe ED Control ED Disposition Priorities Treat and Release ED Clinical Decision Unit Admit/Obs Manage to ED Control over Boarding Measure Times for Admit Pts. 24

26 Where are the Inpatient Beds? Unstaffed Full Reserved Being Cleaned Admissions over the Years 25

27 Getting to an Inpatient Bed Perceived Margin 26

28 Admitting Issues Bed Capacity Day to Day and Seasonal Failure of Planning Lack of Flexibility (M/F, tele, ) Cleaning/Engineering Failure Disengaged Admitting Medical Staff Bed Command Center near ED Headboard Management In-flow Management ED Care Initiation Unit Clinical Decision Units PACU s 27

29 ED Controlled Short Stay Intense Diagnostics, Based on Protocols Intense Therapeutics May not be on Same Floor as ED Staff with APPs Clinical Decision Unit Care Initiation Unit Not ED Controlled Processing non-icu Admits Do Admission Paperwork Efficient In-Processing Feed Patients to Floors Staff with RNs Home for Hospitalists Hospital Flow Strategies: Facility Diagnostic and Treatment areas open 7 days a week Discharge Lounges Room cleaning 24*7 Tele housewide Forbid diversion Bed mgt strategies start Sunday eve 28

30 Hospital Flow Strategies: Nursing Case manage 7 days a week Simplify or consolidate the processing of inpatients, like a Care Initiation Unit Tele housewide Forbid diversion No meeting Mondays Bed mgt strategies start Sunday eve Each unit has reverse triage strategy Hospital Flow Strategies: Doc Hospitalists and Surgicalists Smooth Surgical and Cath schedules Diagnostic and Treatment areas open 7 days a week Simplify or consolidate the processing of inpatients, like a Care Initiation Unit Forbid diversion No meeting Mondays Bed mgt strategies start Sunday eve 29

31 Solutions to the Admitting Issues Admitting Process is recreated with every patient?? Apply Bed Ahead planning Design PUSH + PULL systems to get admissions processed correctly The Sunday Night Work Plan Full Capacity and Disaster Full capacity protocol Disaster response Reason to practice reverse triage daily Justifies flex spaces and flexible staffing Seasonal needs must be planned for with viral surges every few years 30

32 Maximize ED Flow Open Front End Uniform Bed/Room Design Forbid diversion Flow Doctor Manage and Staff a CDU and a Care Initiation Unit No meeting Mondays Daily bed huddle in the ED 31