SQUEEZING WATER FROM A STONE: MAXIMIZE YOUR EXISTING RESOURCES AND ENHANCE YOUR PATIENT FLOW PROGRAM 2011 Becker s Hospital Review Annual Meeting May 19-20, 2011 Lisa Romano RN, MSN Healthcare Reform Much of the coverage of the health care reform law in its early stages has focused on efforts to expand health insurance coverage. But the law has another focus as well.. improving the quality and value of medical care. Hospital Value-Based Purchasing Program The Department of Heath and Human Services (HHS) announced on April 29, 2011 the Hospital Value-Based Purchasing Program, created under the Affordable Care Act. This program provides hospitals with incentive payments based on their performance on health care quality measures such as: How quickly do heart attack patients receive interventional procedures? How often do patients with heart failure get the discharge instructions they need to help them care for themselves? How satisfied are patients with their experience of care at the hospital? April 29, 2011 Don Berwick Administrator, Centers for Medicare & Medicaid Services 1
What can we expect from Healthcare Reform? Effective as of 2012 Physician payment reforms are implemented in Medicare to enhance primary care services and encourage doctors to form "accountable care organizations" to improve quality and efficiency of care. An accountable care organization (ACO) is a type of payment and delivery reform model that starts to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. An incentive program is established in Medicare for acute care hospitals to improve quality outcomes. Healthcare.gov What can we expect from Healthcare Reform? The Centers for Medicare and Medicaid Services begin tracking hospital readmission rates and puts in place financial incentives to reduce preventable readmissions. Effective as of 2013 A national pilot program is established for Medicare on payment bundling to encourage doctors, hospitals and other care providers to better coordinate patient care. Healthcare.gov How can an efficient patient flow program help? Goals Ensure timely access to healthcare for all Improve the quality of care Ensure safe patient outcomes Reduce Hospital Acquired Infections (HAI) Prevent readmissions Strategies for Goal Achievement Obtain immediate notification of patient discharge Decrease bed turnover times Decrease patient wait-times Assign the right patient into the right bed the first time preventing lateral moves Ensure timely transfer of ready patients into ready beds Track patient movement throughout the course of stay Notify physicians real-time that lab/test results are ready Track equipment for efficient retrieval for use during patient transport and loss prevention Immediately locate biomedical equipment so that ordered IV intervention or monitoring is not delayed Reduce exposure to pathogens Contact with Healthcare personnel Biomed Equipment is clean (pumps, monitors) Transport devices are clean (wheelchairs, litters) 2
Characteristics of an organization not practicing Precision Placement a Rocky Road Multiple phone calls Rounds to look for beds Multiple bed meetings Delayed discharge notification Delayed room cleaning Long waits for transport Placement of not-ready patients into Ready Beds Off-service placements with lateral transfer to right-service bed during inpatient stay Extreme examples of Symptoms of Overcrowding (as noted previously) Symptoms of a System-Wide Capacity Issue Delayed/canceled OR procedures Extended ED wait-times ED Hallway Patients ED LWBS (left without being seen) Ambulance Diversion/silent diversions Placement of Patients off-service Delayed Discharge Notification Long bed turnover times Avanti Patient Flow Services 2010 8 Stages of Throughput Gridlock 1. Delayed discharges on med/surg units increases bed occupancy 4. New patients cannot be admitted; ED forced to go on divert; transfers denied and OR cases canceled GRIDLOCK 2. Med/surg floors are full; CCUs/intermediate care units become backed up with patients that can t be moved to med/surg units Avanti Patient Flow Services 2011 3. Hospital operates at critical census; ED and PACU becomes full with patients unable to move to any unit 9 3
Past: Manual World Past: Manual World Bed Meetings, Multiple telephone calls, rounds to look for beds A fragmented process wrought with delays and frustration Do I have a bed on Mr. Smith? When will it be ready? No 3 rd call: Do I have a bed on Mr. Smith 2nd call: Do I have a bed on Mr. Smith? No 4
Characteristics of an organization practicing Precision Placement - A Smooth Path Minimal phone calls Rounds are clinically focused on expediting the transfer of assigned patients into ready beds No bed meetings Immediate discharge notification Housekeeper is dispatched immediately upon discharge notification Timely room turnover Efficient/timely transport of patients Placement of ready patients into Ready Beds Minimal off-service placement Avanti Patient Flow Services 2011 5
Precision Placement Opportunities Elective Schedule Elective Surgery Cases assigned based on scheduled incision time use of confirmed discharge bed for later cases Inpatients going to OR and not returning to beds beds are released and assigned in am to new patients ED cases going to OR before they are transferred to assigned inpatient bed are not assigned a bed prior to leaving the ED Cath Lab Cases that inpatient bed decision is dependent on results of diagnostic cath are not assigned a bed until decision is made go to a post-procedure area Avanti Patient Flow Services 2011 Specialty Service and/or Procedure Placement(s) Orthopedic Cardiac Neurology Neurosurgery Peritoneal Dialysis Chemotherapy Traction/joint devices Negative Airflow Lead-lined Rooms Bariatric Surgery/Rooms Discharge Planning Milestones 6
PatientTracking Portal XT (Nursing Unit View) Bed Assignment Priority Indicators The electronic bedboard (Patient Placement View) BPIs are easily assigned on the Portal list views. BPIs are displayed on the bedboard for Patient Placement. BPIs can also be assigned from bedboard. Portal XT: Inpatient Units and Source Admission Areas (PACU, A & E, Cath Lab) can stop calling for Bed Assignment/Status Information Bed control uses BedAhead Priority Indicators to make assignments 7
Time for placement strategy. Unnecessary phone calls are eliminated. Nursing units use portal and the bedboard to communicate and receive their real-time bed information. Charge Nurses enter BedAhead Priority Indicators Patient is moved when bed is clean Centralized Bed Control assigns bed using BedAhead Avanti Patient Flow Services 2011 Beds upgraded by Bed Control to Clean Next or Stat as indicated Status of Bed is updated real-time on BedBoard & Portal Admission Source areas refer to BedBoard & Portalfor bed assignment Patient Placement assigns a bed in the order preferred by nursing, ensures prompt room turnover,and notifies destination area of ETA and clinical condition in under a minute Uses Bed Ahead Upgrades to a clean next or stat if necessary Instant Notify used to inform destination of critical update Patient Logistics Implementation: Key Elements Timely notification of patient discharges (Transport Tracking Implementation) Timely turnaround of discharge beds (BedTracking Implementation) Timely assignment of ready beds (PreAdmit/Electronic bedboard Implementation) Timely movement of patients to ready beds ( Pull system) Avanti Patient Flow Services 2011 8
Central Patient Transport Central Patient Transport assumes responsibility for all discharge escort Discharges are assigned a high-priority in system Reporting structure changed to patient logistics Transport Tracking Software used Real-time interface with BedTracking and PreAdmit Tracking results in: immediate notification that discharge has occurred Immediate dispatch of cleaning job to housekeeping Avanti Patient Flow Services 2010 DBST - Discharge Bed Swat Team Team of dedicated housekeepers Devoted to cleaning of discharge and transfer beds only Staggered shifts based on dirty bed hourly distribution Dispatched to clean dirty bed via BedTracking Uses alpha pager and bedside phone to communicate updates No competing priorities Avanti Patient Flow Services 2010 Automation with Precision Placement founded on Best Practice Patient Flow Strategies yields Incredible Results 9
Avg Minutes on Hold per Month Avg # Cases on Hold per Month Bed Aborts # of Transfer Center Requests Case Study #1 1000 bed Level 1 trauma and burn center across three campuses. Problem Statement: Overcrowding and lost business from ED LWBS and Transfer Center denials due to bed availability. Solution: Implementation of TeleTracking CMS along with centralization of patient placement and transfer center for multiple campuses Results (scorecard) Transfer Center admission growth 20% admission growth over 3 year period all campuses all patient types Dramatic Reduction in Operating Theatre Hold Reduction in A & E wait times Bed Turns at top quartile (advisory board measure) Improved A & E patient satisfaction Requests continue to rise while bed availability refusals decline as A more efficient bed search process across 3-campus system allows Transfer center coordinator to confirm acceptance within 10 minutes of call Transfer Center Aborts due to Bed Availability Jan 2003 - Jan 2006 % Bed Aborts Total Trans. Req Total Trans Req Trend % Bed Aborts Trend 16% 14% 12% 10% 8% 6% 4% 2% 0% 440 420 400 380 360 340 320 300 280 260 240 220 200 180 160 140 120 100 80 60 40 20 0 Jan-03 Mar-03 May-03 Jul-03 Sep-03 Nov-03 Jan-04 Mar-04 May-04 Jul-04 Sep-04 Month Nov-04 Jan-05 Mar-05 May-05 Jul-05 Sep-05 Nov-05 Jan-06 Dramatic Reduction in OR HOLD LVH-CC OR Long Holds Monthly Avg by Year 1,200 1,050 900 750 600 450 300 150 0 Minutes OR on Hold Cases on Hold 40 2003 2004 2005 2006 2007 Year 35 30 25 20 15 10 5 0 10
Acute Inpatient Admissions Growth Rate Press Ganey Percentile % of Patients LWBS # of ED Visits Left Without Being Seen in Emergency Department ( A & E) ED Patients Left Without Being Seen (LWBS) % LWBS ED Visits 3.0% 2.5% 70,000 60,000 2.0% 1.5% 1.0% 50,000 40,000 30,000 20,000 0.5% 0.0% 2003 2004 2005 2006 2007 % LWBS 2.8% 1.9% 2.1% 2.0% 1.6% ED Visits 49,187 49,896 53,288 56,099 59,448 10,000 0 Calendar Year Patient Satisfaction ED Patient Satisfaction CC-ED percentile rankings 100 80 95 85 70 77 60 40 30 20 0 2003 2004 2005 2006 2007 Patient logistics/ Teletracking implemented Fiscal Year Bed turns began at 48 and increased to 62 Acute Admissions Network Admissions Growth Rate 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 Fiscal Year 3.8% 0.7% 1.7% 1.4% 6.2% 5.3% 8.4% 1998 1999 2000 2001 2002 2003 2004 2005 2006 BedBoard implemented 20% admission growth over next 3 years 2.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% -2.0% 11
Meeting Industry Standard: Do we meet the Advisory Board s Expectations? Sample hospital with Centralized Bed Control and Best Practice Use of Patient Placement Technology BedTurns (staffed beds divided by # of admissions annually) average annual bed turns top quartile 61* 100 90 80 70 60 50 40 30 20 10 0 78 79 78 78 78 78 Jan Feb Mar April May June BedTurns (staffed beds divided by # of admissions annually) * Benchmark source: Advisory Board True North Publication Case Study #2 Premier medical facility with > 1800 beds and an impressive array of specialty services Problem Statement: Overcrowding and lost business from ED LWBS and Transfer Center denials due to bed availability. Solution: Implementation of TeleTracking CMS along with centralization of patient placement and Transfer Center across multiple campuses Results (scorecard) Impressive Transfer Center admission growth Reduction in time from bed request to assignment Reduction in A & E wait time 12
2009 58,000 visit ED No Diversion Policy LWBS (Left Without Being Seen) 400 350 336 300 299 250 200 150 100 189 170 152 153 191 115 194 146 98 50 0 Jan Feb Mar April May June July August Sept Oct Nov # pts Total Transfers (Oct '09-March '10) Total Transfers: 644 Total Transfers: 477 Total Transfers: 479 Total Transfers: 464 Total Transfers: 441 34.0% 1% Growth Growth 3.0% from Total Transfers: from Feb 352 (3%) 5.2% Growth Jan Growth from from Dec 25% Nov Growth from Oct 341 (97%) 424 446 466 469 (96%) (96%) (98%) (98%) 639 (99% ) Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 March '10 13
Best Practices to maximize use of Patient Flow technology Entry of pending discharge Update pending to confirmed with use of precision placement Transport escort of discharges with interface to bedboard Transport discharge escort interface to housekeeping to clean the bed Dedicated cleaning team for discharge and transfer beds Use projected census to better align resources with demand Centralized Bed Control with use of BedAhead to assign beds Use of Discharge Planning Milestones to facilitate early discharge and precision placement Transparency of information Implementation of a Pull System Data driven patient flow program with goals for all patient flow stakeholders incorporated into performance evaluation 14
Create a Pull System Pull Systems ensure Timely Movement of Ready Patients to Clean & Ready Beds Rapid, Streamlined communication between feeder areas and patient units Capacity Management Software Avoid phone tag unnecessary phone calls Hold staff accountable to timely transfer/patient acceptance Bed Alert: M/S near full-capacity LLM/High-level at full-capacity 20 post-ops, 7 ED holds, projected census to hit 99% within 3 hours Provide Community Command Center with Real-time Bed Capacity Information The powerful impact of Remote Locationing Systems (RTLS) on patient flow Integration of RTLS into the Capacity management Suite (patient flow software) allows for immediate decisions based on realtime patient movement information. This becomes the foundation of Precision Placement. Immediate discharge notification Immediate page to housekeeping to turnover bed when discharge occurs Immediate notification that transfer of patient has occurred (or didn t occur) into assigned bed Continuous updates on location of hallway/overflow patients Ability to immediately locate necessary equipment 15
About Teletracking RTLS A Real-Time Location System (RTLS) that uses a combination of reverse IR and traditional RF (estimated) technologies to track people and assets. 100% bed-level accuracy Timely, robust data Network-friendly Easy installation Power-efficient Low Total Cost of Ownership Track at zone, room, or bed level = Beacon = Virtual Walls = Eth. Collector = Wi-Fi Collector No Hallways (room) Asset Management Patient Tracking Workflow Hallway only (zonal) Asset Tracking Choke Points (zonal) Asset Tracking Full coverage (bed) Staff Locating / Nurse Call Hand Washing Compliance Asset Management Patient Tracking Workflow Questions? Lisa Romano RN, MSN Sr Vice-President & Chief Nursing Officer, TeleTracking Technologies, Inc. (610) 504-3078 Lisa-Romano@teletracking.com 16