REPRINT APRIL 2012 Nancy A. Nowak Holly Rimmasch Ann Kirby Chad Kellogg healthcare financial management association www.hfma.org right care, right time, right place, every time Intermountain Healthcare implemented a new patient flow process, improving quality and efficiency and increasing bed capacity. When Intermountain Healthcare opened its new 448-bed flagship Intermountain Medical Center (IMED) in Murray, Utah, in 2007, the facility immediately attracted more patients than originally projected. Some patients were kept in the emergency department or postanesthesia care unit (PACU) waiting for a bed; others were placed in any bed available. Housekeeping was beset with STAT bed-cleaning requests. Patient flow problems were creating a difficult environment for both patients and employees. methodology at seven more hospitals. The remaining three will complete adoption in 2012 and 2013. The patient flow challenges IMED was experiencing were ripe for the kind of innovative approach to process redesign that has served Intermountain well in many areas of care delivery. Its institutional commitment to extraordinary care encompasses the following dimensions: > Clinical excellence > Service excellence > Physician engagement > Operational effectiveness > Employee engagement > Community stewardship Intermountain used the patient flow challenge at its new hospital as an opportunity to redesign patient flow in its 11 largest hospitals. The organization implemented a new patient flow process at IMED in early 2009, and has since adopted the Better patient flow enhances all of these areas. For example, reduced delays and wait times improve both clinical and service excellence. Better communication about matching patients with available resources increases engagement of hfma.org APRIL 2012 1
The project's guiding principle was to remove variation from patient flow processes, increase collaboration, and enhance the quality of care. AT A GLANCE > By improving its patient flow, Intermountain Healthcare was able to increase capacity and improve resource utilization. > The project's guiding principle was to remove variation from patient flow processes, increase collaboration, and enhance the quality of care. > A pilot project to redesign patient flow at Intermountain Medical Center focused on patient placement and care coordination. > The pilot resulted in the creation of 21 virtual beds, reduced severityadjusted average length of stay, enhanced patient satisfaction, and improved bed turnaround time. both physicians and employees, and increasing bed capacity without investing additional capital makes for a more effective operation and better use of community resources. Intermountain established a steering committee to oversee the patient flow initiative. The committee included both system and hospital executive leadership: chief nursing officers (CNOs), chief medical officers, CFOs, administrators, and compliance and other clinical and financial leaders. The committee presented a proposal to its senior leadership to address patient flow at the organizational level, setting the following goals: > Optimize patient flow processes > Enhance quality of care provided > Increase effective capacity and improve resource utilization > Create stronger relationships with physicians, staff, and patients > Create a consistent patient flow and bed management culture > Provide real-time information and processes needed to manage the facility and guide improvement efforts > Facilitate and enable the mission of Intermountain Healthcare A System Approach from the Start Most of Intermountain's hospitals did not have the capacity issues faced by IMED, but leaders believed that maximum benefit could be obtained by making patient flow policies and practices consistent across the system. The challenge was to create best practices that could be adopted consistently in all the target facilities, which range in size from 48 to 448 beds and vary in level of acuity and specific services provided. The project's guiding principle was to remove variation from patient flow processes, increase collaboration, and enhance the quality of care. Under the direction of the steering committee, joint teams representing 11 of the largest hospitals in the Intermountain system planned several fundamental changes in the organization's approach to patient flow. These changes would include workflow and process reengineering in the areas of patient placement, environmental services, care coordination, and case management as well as implementation of software tools to aid coordination and track performance. These changes were initiated at IMED, the pilot site for the new approach. The pilot approach and results for each of the areas targeted for workflow and process reengineering are described below. Patient Placement The medical center team implemented an electronic bedboard, a dashboard-type tool that is used and overseen by the patient placement department. This tool allows patient placement staff to view the status of all inpatient beds within a facility (occupied/dirty/empty) and, assign patients to units and beds, using an interface akin to an airline s online seat-selector. Environmental services staff also use the bedboard to coordinate bed cleans. The team also designed and implemented a centralized patient placement process that included the effective use of the bedboard tool. For example, a bedboard can assign a patient to a unit or to a bed. Assigning to the unit builds in automatic delays in the placement process. By assigning all the way to the bed, patient placement staff can expedite the process. In addition, the tool views can be set up to be more in line with the processes implemented, making the tool customized to the process, rather than adjusting the process to the tool. As part of the admission, the 2 APRIL 2012 healthcare financial management
patient placement department assessed all patients to determine the level of care required and targeted their admission to the appropriate unit based on their diagnosis and level of care. Registered nurses were trained in the use of an additional software tool that made the level of care assessments consistent. The new patient placement approach reaped the following benefits. Improved accuracy and efficiency of patient placement. The initial assessment helped the team ensure that each patient was placed in the appropriate unit. A single, central point of contact and accountability for patient placement. The patient placement department created clear roles, structure, and process for moving patients through admissions. Consistent assessment of the appropriateness of admissions. The patient placement department used a CMS-accepted tool to help determine the level of care needed for a patient. The tool helps ensure that the patient is placed in the most appropriate place for care, removes variation from the process, and reduces the possibility that the admission will be denied. More effective alignment of environmental services staffing levels to meet discharge and transfer demand. The electronic bedboard helped track which rooms were empty and in need of cleaning so that they could be turned around as quickly as possible. In addition, realigning staff schedules to meet the demand throughout the day improved the turnaround time without requiring additional staff. At IMED, these measures resulted in a 50 percent decrease in bed turnaround time (from 88 minutes to 44 minutes), and a 92 percent decrease in STAT bed clean requests. Care Coordination The medical center held daily multidisciplinary care coordination meetings on each unit that included all the care team members for each patient. A process was put in place to anticipate and communicate patient transitions from admission through discharge. The care coordination teams mandate included involving both patient and family in the discussion of care plans. Benefits of care coordination improvements included the following. Improved patient satisfaction and quality of care. Patients who feel their entire care team understands their plan for treatment are happier with their care. And when all members of a care team understand the plan of treatment, they can work in concert to deliver the right care at the right time. Patient feedback at IMED showed the difference: IMED experienced improvement in eight targeted patient satisfaction questions related to patient flow three Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and five Patient s Perception of Quality questions. Four of the eight questions showed statistically significant improvements. Increased interdisciplinary clinical team awareness of the patient population, plan of care, and discharge planning process. More comprehensive information helps move the patient through the treatment plan efficiently and effectively. By improving interdisciplinary communication, IMED was able to reduce severity-adjusted length of stay by nearly seven hours. The medical center also increased the accuracy of predicting and communicating next-day patient discharges from 0 percent to 47 percent. Similar results were seen in all hospitals that implemented the solution. About Intermountain Intermountain Healthcare is a not-for-profit health system based in Salt Lake City and serving residents of Utah and southeastern Idaho. The system includes 22 hospitals, almost 200 clinics, more than 900 multispecialty physicians and caregivers, and 32,000 employees. Intermountain s health plan, SelectHealth, has more than 530,000 members. hfma.org APRIL 2012 3
Case Management After analyzing the needs of case managers and social workers by observing their workflow processes and conducting interviews, the medical center implemented a unit-based staffing model and a documentation tool to help the case management team manage its daily work. During the observation phase, the team noted an inconsistency of documentation standards and found the tools they were using to communicate progress on activities such as utilization management and discharge planning were inadequate for the job. The documentation tool the team implemented produced the information needed to track metrics, such as level of care assessed within one day of admission, initial screenings within one day of admission, and level of care not met. It also incorporated documentation standards to promote consistency and timeliness in communication. The team was trained to use the tool through both group training and one-on-one, on-the-job training, which included training sessions with case managers and social workers to ensure that everyone was on the same page. Keys to Maintaining Patient Flow Systemwide Sustaining patient flow process improvements requires continued focus not only by hospital staff and clinicians, but also by the top executive leadership at both the hospital level and system level. Hospitals and health systems can take a lesson from Intermountain by taking the following steps to implement and sustain patient flow improvements consistently across their organizations: > Create a focused patient flow team at the system level that includes representation from individual facilities. This team is responsible for setting strategic direction and minimizing system variation. > Develop internal experts to assist with implementation and project plans. > Hold consistent operations meetings at each facility and review all relevant metrics to give clinical and nonclinical personnel the opportunity to see that everyone is held accountable. > Tie staff performance in key metrics to performance reviews. > Provide weekly executive summary of patient-flow metrics to system and local leadership. > Establish board-level goals for patient flow metrics, giving the board the information to maintain accountability for push for continued performance improvement. These steps yielded the following benefits. Better consistency of utilization review and discharge planning. Driving out variation through level of care assessments with the help of the CMSaccepted tool improved performance especially at vulnerable transition points during a patient s care. Improved financial outcomes for patients and for Intermountain. Proactive discussions with insurance companies and consistent level of care assessments created more timely, accurate, and predictable payments. Tools and metrics. To analyze data generated by the new tools and other information systems throughout the facility, Intermountain implemented a reporting tool. The system generates reports on key metrics, such as boarding time, bed placement time, off service placement at admission, anticipated discharge within one day of admission, level of care documented within one day of admission, anticipated discharge accuracy by patient, and bed turnaround time. The data are reviewed and discussed in a weekly meeting of all key stakeholders involved with patient flow. Good performance is celebrated, and areas that need focused attention are discussed. Appropriate members of the team are then assigned to develop a proposed plan of action for resolving problem areas by the next meeting. The tools provided the following benefits: > Metrics that drive performance > Transparency > A collaborative approach Daily and weekly metrics help drive accountability as well as empower teams to make proactive rather than reactive interventions. Making performance transparent across the organization drives accountability and a focus on continuous improvement. 4 APRIL 2012 healthcare financial management
By fostering a collaborative approach, the tool helps remove barriers and improve flow. Rather than finger-pointing, teams can use the metrics to identify and eradicate barriers to performance improvement. For example, a delay in removing a patient s belongings from a room when the patient is transferred creates a delay for the environmental services team. To address this problem, nursing and environmental services leaders created a process to ensure timely removal of patient belongings, which improved bed turnaround time. Pilot Outcomes Over 11 months, the pilot patient flow redesign project at IMED achieved the following results: > Creation of 21 virtual beds (the amount of extra capacity generated by using existing beds more efficiently) > Reduction of 6.78 hours in severity-adjusted average length of stay > Enhanced patient satisfaction > Improved bed turnaround time by 50 percent Implementing the New Patient Flow Strategy Across the System To ensure that the new patient flow processes would create the same peak performance culture and outcomes at facilities across the Intermountain system, patient flow leadership needed to address several key organizational issues. Determine system-level and facility-level infrastructure and roles. Intermountain established a systemlevel leadership team for patient flow, the Patient Flow Guidance Council, composed of system-level executives, internal patient flow project team members, regional CNOs, and nurse administrators from each hospital in the system. This team uses patient flow tools to track facility performance across the entire organization. They also make all key decisions on system goals and core processes. Facility-level leadership teams are responsible for using the systemwide patient flow report to PATIENT FLOW ORGANIZATIONAL INFRASTRUCTURE Patient Flow Entities and Meetings Members Roles Frequency of Meetings Steering Committee System and hospital executive Set system-level goals Monthly through the leadership: CNOs, CMOs, for patient flow. implementation of the first four CFOs, administrators, and facilities compliance and other clinical and financial leaders Patient Flow Guidance Council Regional CNOs and hospital Review metrics and performance Monthly nurse administrators plus across all facilities; establish system-level executives patient flow processes systemwide, support continuing improvement of best practices. Patient Flow Meeting Leaders from nursing, case Review metrics and performance Weekly (Facilities that management, environmental across key patient flow demonstrate high performance services, patient placement, departments; celebrate have gone to a biweekly schedule. physicians, emergency successes; collaborate on If metrics begin to slip, the department, postanesthesia removing barriers; make sure facility goes back to a weekly care unit processes are continuing to be meeting schedule. ) effective and efficient; hold leadership accountable to maintaining/improving patient flow performance. Unit-Level Multidisciplinary Nurses, physicians, case Ensure that all care team Daily Care Coordination Meeting managers, social workers, members are aware of patient s ancillary services care plan; communicate plans with patients; work together to meet patient care goals. hfma.org APRIL 2012 5
gauge their progress against other Intermountain facilities. They are also accountable for ensuring that their facilities adhere to the goals and core processes established by the Patient Flow Guidance Council. There is room for individual facilities to vary their execution of those core processes, but variances must be approved by the system-level team. For example, the Patient Flow Guidance Council established that facility-level patient flow meetings should be held weekly. Two facilities lobbied to begin holding their meetings less frequently monthly rather than weekly because they were consistently meeting their target patient flow metrics. The groups agreed on a compromise: The facilities would meet weekly, and if their numbers held for several months, they could go to biweekly meetings. But if their numbers started slipping, they would need to go back to weekly meetings. Ensure broad ownership of patient flow goals. Because the Patient Flow Guidance Council includes facility representatives, each facility has input on all decisions, which helps ensure broad ownership of patient flow goals and support for system-level decisions. Keep top patient flow performance a priority. Even after the project started to show significant improvements in patient flow, system leadership kept it as a primary focus, issuing regular reports to system and facility executives, stressing the importance of consistent review at the facility level, and keeping patient flow on the agendas for regional and systemwide meetings of CNOs and other top executives. Outcomes As a result of the pilot, Intermountain achieved several successes across the system. New patient flow processes and tools were implemented at McKay-Dee Hospital, Utah Valley Regional Medical Center, Dixie Regional Medical Center, Valley View Medical Center, LDS Hospital, and Alta View Hospital. A regional patient placement department was created for the Southwest Region and Central Region. In addition, consistent case management practices were implemented across all target hospitals. Improved processes created more efficient use of space and added de facto additional capacity, creating 89 virtual beds across seven hospitals. Now Intermountain has the capacity to serve 10,434 more patients annually. Conclusion Each patient flow stakeholder has undergone a fundamental change in the pattern of his or her workday, with the following benefits. Nurses and physicians. Regular daily care coordination meetings enable nurses to proactively manage patients, reducing the need to track down a physician for each care decision. More efficient overall bed utilization gives patient placement nurses the confidence to take a few extra minutes to admit the patient to the most appropriate bed rather than rushing for the first one available. Environmental services leadership. Participation in weekly patient flow meetings adds to the department's visibility and motivates the team to increase efficiency. Case managers. Clear delineation of responsibilities and patient flow measurement tools have given case managers a better understanding of their role and the information necessary to do their jobs more effectively. Patient placement staff. Access to patient-flow data improves these staff members understanding of flow in their facility, and increases their ability to communicate with the rest of the staff. They no longer need to work around inefficient processes, and other members of the healthcare team trust them to place patients appropriately. Patients and families. Improvements in patient flow have decreased waiting times for patients and their families and helped them understand the care plan and when key care events will happen, improving satisfaction. 6 APRIL 2012 healthcare financial management
CASE STUDY The organization has also seen positive ripple effects systemwide from improved patient flow processes. Because patient flow processes are standardized across the Intermountain system, changes in regulations and processes can be handled more efficiently. Patient placement nurses now review the patient status order and discuss any concerns with physicians. Case managers more consistently review each admission within 24 hours, and thereafter as indicated for each patient, using utilization review criteria. Both changes have minimized financial risk. Tighter control of resources and centralized reporting have created stronger integration between financial and clinical staff. Intermountain is now equipped to continue to improve patient flow performance, setting and meeting increasingly ambitious performance goals, while improving quality and efficiency. By doing so, the organization is also demonstrating its deep commitment to the communities it serves, advancing its mission and leading the way in setting best practice standards for the delivery of health care. Tighter control of resources and centralized reporting have created stronger integration between financial and clinical staff. About the authors Nancy A. Nowak, RN, MA, is vice president clinical operations and chief nursing officer, Intermountain Healthcare, Salt Lake City (Nancy.Nowak@imail.org). Holly Rimmasch, MSN, RN, is assistant vice president, clinical services, Intermountain Healthcare, Salt Lake City (Holly.Rimmasch@imail.org). Ann Kirby, MSN, MPA, is a managing director, clinical solution, Huron Healthcare, Chicago (akirby@huronconsultinggroup.com). Chad Kellogg is senior director, clinical solution, Huron Healthcare, Chicago (ckellogg@huronconsultinggroup.com). Reprinted from the April 2012 issue of hfm magazine. Copyright 2012 by Healthcare Financial Management Association, Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154. For more information, call 1-800 -252-HFMA or visit www.hfma.org. hfma.org APRIL 2012 7