CASE STUDY Saint Luke s Improves Patient Flow with Help from Apogee Informatics Corporation and ithink Between television and personal experience, most people have a sense of what goes on inside a large city hospital s Emergency Room. There are no appointments, some days are busy and chaotic, others less so. Experience lends some predictability about when more nurses or doctors might be needed but there s no telling what will happen on any given day. Staff has to be ready to treat whatever patient and problem comes through the door whether an elderly man suffering a stroke, an infant with the flu, or a teenager with a gunshot wound. Like every Emergency Department (ED) across the nation, we re dealing with a flood of patients, explains Denise Mogg, Director of Emergency Services at Saint Luke s Health System in Kansas City, Missouri. The movement of that flood through the ER; entry, admissions, triage, testing, diagnosis, treatment, dispensation, is called patient flow. A set of metrics that describe and monitor patient flow is an important yardstick for quality of care. The less time a patient spends waiting for care, the better chance of a good outcome. The faster patients can move from the ED into the hospital, the more capacity ED staff has for incoming new cases. Saint Luke s is starting to see significant improvements in patient flow, increases in quality of care and positive trends in patient and employee satisfaction. That s no small feat for any metropolitan ED, let alone one that sees and treats the sickest patients. While it s typical for 10-15% of a hospital s patients to be admitted through the ED, 25% of Saint Luke s patients start out in Emergency. Saint Luke s efforts to continuously analyze and improve ED processes have been widely recognized. In 2003, Saint Luke s received the prestigious Malcolm Baldrige National Quality Award and in 2006 the Missouri Quality Award. Those achievements are, in large part, a result of in-house efforts that began three years ago and more recent utilization of Apogee Informatics Corporation OpenED solution and ithink Systems Thinking software from isee systems. About OpenED OpenED from Apogee Informatics Corporation is a unique combination of specialized services, real-time dynamic simulations, and instrumentation that help clients to improve patient flow. Consulting directly with ED and hospital staff, Apogee customizes visual computer models to emulate exact workflows, timeframes and relationships associated with patient care from the ER waiting room and triage through to discharge and into inpatient areas. When linked to specific scenarios including clinical, operational, and financial situations, these models provide staff with rarely seen enterprise views of their own clinical and business processes and why things work the way they do. Saint Luke s Improves Patient Flow Page 1
About ithink ithink Systems Thinking software from isee systems guides teams through the creation of models that simulate processes and scenarios; pointing out the impacts of a new procedure or policy, creating shared insight, and offering opportunity to fix undesirable outcomes. Based on Systems Thinking, ithink goes beyond spreadsheets and other linear approaches to planning to provide a big picture view of operations. Models and simulations identify key leverage points for improving performance serving as "practice fields" by revealing successful outcomes and those that could be painful, costly, or embarrassing if discovered in reality. Patient Flow Issues at Saint Luke s Several years ago, historical data that we collected through our electronic tracking board, showed us that waiting times were up, length of stay was up, and patients and staff were unhappy, remembers Mogg. We knew we had a process issue. Not only were patient flow problems hard on staff that truly wanted to provide excellent care, its impact on patients made it a business liability. People are becoming better informed health care consumers. They don t sit back and say Oh I ll wait for 6 hours. They have choices. Mogg and others in the department knew that the key to improvement was learning how to spot and fix patient flow issues before they became a problem. We needed to see what was happening throughout the department and become proactive. We could react to patients rolling in the door, but we wanted to leverage what we knew from historical data to make better decisions before we had a problem. They also knew that while all EDs have similarities, it is their differences that can make the biggest impact on patient flow within and outside the ED. We couldn t use cookie cutter solutions. And we couldn t just look at the ED. We needed to understand capacity and gridlock in the whole hospital, to look at processes across the continuum of care. Laying the Foundation for Change Under Mogg s guidance and with the support of all levels of hospital management, eight teams representing various components of ED service spent one year methodically examining their processes to see what we do well, where we need improvement, and how changes would really impact the system. Saint Luke s Improves Patient Flow Page 2
All teams included nurses, physicians, and members of the quality department. They were divided by sections of work and included: Triage ER Central supply Admitting processes Patient tracking Quality Lab services Radiology The teams took the whole system apart. Using historical data, they looked at patient flow in each section. The objective was to determine what changes should be pilot tested and how metrics would be impacted. Along the way, an emergency medicine physician/consultant who was asked to evaluate Apogee Informatics Corporation suggested that the group look into their services. Apogee offers industry expertise and technology to healthcare clients challenged with providing high quality care at an affordable price. Saint Luke s met with Apogee and discovered a new method of analyzing system improvements to ensure success. The Apogee Informatics Corporation Solution: Applying Systems Thinking to Patient Flow Apogee Informatics Corporation creates customized models of health care delivery systems and then uses those models to simulate outcomes given a variety of variable inputs. ithink is used to create models and run simulations, in effect offering practice fields for idea testing where painful, costly, or embarrassing impacts can be discovered free of risk. By the time Apogee met Saint Luke s, the teams there had already assembled data on patient age, entry date, reported problems, diagnoses, disposition decision, length of wait and a host of other metrics that describe patient flow into, through, and out of the ED. Apogee created a model of Saint Luke s current system taking care to identify the principle patient value streams within the hospital and demonstrate how any of over 250 variables (patient illness and severity, staffing, ancillary services, mode of arrival, occupancy within the hospital, etc.) dynamically effect patient flow. The model allows any combination of process changes under any variation of conditions. The model accounts for almost every type of patient and path of care, explains David M. Klubert MD, President of Apogee Informatics Corporation. All inputs come from Saint Luke s actual data and simulations show near real-time views of patient flow. Saint Luke s Improves Patient Flow Page 3
Quick Lessons, Lasting Improvements We had done so much work before creating a model that we didn t have any real ah-has or surprises about our system, says Mogg. We knew what was working and what wasn t. Simulations, however, did offer some quick insight. We tested ideas for improvements that we thought would be great, and they weren t. We hadn t anticipated the impact those ideas would have on other parts of the ED process or hospital. When you think about it, every ED doctor and nurse works in the moment. It s common sense that if you make this change you ll fix that problem but you can t really see how things will happen throughout the system. Simulations let you take a step back and see what a change would really look like. Mogg points to the example of staffing level change. By using historical data in the model we can look at busy and slower days as well as different times of day or week. We can vary the number of staff and simulate what happens to patient flow. When we run simulations before piloting an idea we save ourselves from making real mistakes and wasting time. With the help of Apogee and ithink, Saint Luke s did simulate, evaluate, pilot test, and implement changes that have effectively reduced patient wait times in the ED. They have also improved processes used to treat patients who are having acute myocardial infractions and are now using that experience to improve their stroke care service. Mogg recognizes that change is difficult, especially when it is made in such complex environments and touches so many people. This solution gives us a big opportunity with staff. We can say This is us. This is our history. These are our patients. When we come up with solutions we can really explain them and get buy-in. Then we see immediate results. Continuous Improvement at Saint Luke s Having already seen results from their modeling and simulation experience, Saint Luke s plans to keep going. Charge nurses have access to models and will be using instrument panels (with real-time data) to get a heads up on slowdowns. The twice daily bed briefing that examines need and availability is also taking advantage of the ithink models Apogee has in place. We can see why something worked yesterday but not last week and figure out if it will work today. Mogg looks forward to embedding models and simulation feedback into bed briefings and continuing analysis of how ED processes impact, and are impacted by, other areas of the hospital. She thinks that Saint Luke s is unique in their efforts. A lot of hospitals have experience with modeling and simulating ED processes but we re starting to look at the hospital as a whole. Saint Luke s has already evaluated multiple alternatives to its triage systems, its physician and nursing staffing levels, and its use of Fast Track and expedited pathways for trauma, stroke, and chest pain. It is currently piloting the location of a safety net clinic next to its main ED. In a unique application of simulation, Saint Luke s will collaborate with another hospital using their respective models and actual data to explore lab testing. Saint Luke s Improves Patient Flow Page 4
Saint Luke s and Apogee both see benefit in sharing models and simulations with other hospitals and EDs. It s great to look at some challenges with good outcomes. That increases the rate of learning. And it s great to not feel alone, says Mogg. Klubert points out that Apogee has found ways to test those processes thought to represent best practice from one hospital within an entirely different hospital model to quickly establish any potential value. After a while, it gets easier and easier. Other hospitals could learn a lot from Saint Luke s. We really work hard on continuous improvement and have support from the CEO and COO on down, says Mogg. There is a lot of time and resource put into it. When I have data and a working simulation I can go to the CEO and say Here s what the ED needs to do and here s what the house has to do and he supports the solution presented. About Saint Luke s Health System (www.saint-lukes.org) Saint Luke s Health System includes 11 hospitals and several physician practices in the Kansas City metropolitan area and surrounding region. A teaching hospital, Saint Luke s coordinates with the University of Missouri Kansas City schools of medicine and nursing. Saint Luke s Hospital is a Level 1 trauma center and includes the MidAmerica Heart and Brain Institutes. About isee systems (www.iseesystems.com) isee (formerly High Performance Systems) is the world leader and innovator in Systems Thinking software. Founded in 1985, isee released STELLA, the first software application to bring Systems Thinking to the desktop. In addition to STELLA which is primarily used by educators, isee offers ithink for business simulation. isee is a privately-held company with substantial global reach in business, education, and government markets. About Apogee Informatics Corporation (www.apogeeinformatics.com) Apogee creates a variety of tools that model current process flow, emulate past performance, and display real data for improved decision making. Its consultants are skilled in guiding clients in developing dynamic simulations to measure and improve patient flow throughout the continuum of care. The Apogee process rapidly inserts models, experience, and expert services into organizations efficiently and cost effectively. Clients learn to quickly identify and solve problems. For more information, contact: Kerry O Connor Joanne Egner Director of Public Relations Managing Director Saint Luke s Health System isee systems, inc. Email: koconnor@saint-lukes.org Email: jegner@iseesystems.com Phone: (816) 932-8646 Phone: (603) 448-4990 David Klubert President Apogee Informatics Corporation Email: david_klubert@apogeeinformatics.com Phone: (256) 722-3001 Saint Luke s Improves Patient Flow Page 5