Creating a Pull System in a Push Dominated Environment

Creating a Pull System in a Push Dominated Environment 1 Creating a Pull System in a Push Dominated Environment Todd Schneider, Improvement Advisor Julie Allison, Project Manager Tallahassee Memorial HealthCare 2 Background Tallahassee Memorial HealthCare Tallahassee Memorial HealthCare 770 licensed beds 24,000 annual inpatient admissions 67,000 annual Emergency Dept visits Recipient of the Pursuing Perfection: Raising the Bar for Healthcare Improvement grant from RWJF IHI Flow Innovation team member Tallahassee Memorial HealthCare (TMH) has 770 licensed beds (597 bed tertiary, 60 bed psychiatric hospital, 53 bed sub acute, and 60 bed long term care), 2 home health agencies, 7 family medicine practices, Family Practice residency program and state-of-the-art health and fitness facility. TMH has 435 physicians and serves a population base of about 600,000 in 16 counties of N. FL, SW GA and SE AL. Tallahassee Memorial is a private, not-for-profit, fullservice system, which has served its community for over 50 years. TMH is the safety net provider for the area, providing over $35 million last year in uncompensated care. Tallahassee Memorial Hospital has 24,000 annual inpatient admissions and 67,000 Emergency Department visits. Tallahassee Memorial HealthCare was awarded the Pursuing Perfection: Raising the Bar for Healthcare Improvement grant from the Robert Wood Johnson Foundation. This grant was created to show that system-wide quality improvement efforts are feasible and to set new benchmarks for health care quality and safety. The Institute for Healthcare Improvement (IHI) is the National Program Office for the grant and has been providing technical assistance to the grant recipients. TMH has also been a member of IHI Flow Innovation team. This team of 6 hospitals has been testing various changes and concepts that can impact patient flow throughout the hospital. T. Schneider, J. Allison Page 1 of 18

Creating a Pull System in a Push Dominated Environment 3 Outline Transition from Early Discharge to Discharge Scheduling Lean Healthcare = Discharge Scheduling Methods to facilitate change Financial Impact of Changes Next Steps 4 Healthcare Realities Emergency Department visits are increasing Reimbursements are decreasing Healthcare organizations are struggling to remain profitable As we are all well aware, the healthcare industry is in an interesting place. Emergency visits across the nation are increasing, while the number of Emergency Departments are decreasing. Reimbursements have decreased over the years, which has introduced a new financial structure for healthcare organizations. Also, many healthcare organizations are struggling to remain profitable amidst all of this change. 5 What s Constant? Emergency Department admissions Direct admissions from MD office Beds unavailable when needed Numerous afternoon discharges However, there are some areas that organizations should not be surprised at. For example, many organizations have a daily problem with the admission of patients from the Emergency Department. Administrators and Managers should not be surprised when the Emergency Department calls for an admission. In most organizations, the number of the daily ED Admissions are relatively constant. In fact, some organizations (like Tallahassee Memorial) have less day-to-day variability in their ED admissions that they do with the elective surgical admissions. The same can be true with the number of Direct Admit patients from Physicians offices. Much of the problem is a lack of beds at the appropriate times. In many organizations this is largely due to the large number of afternoon discharges. T. Schneider, J. Allison Page 2 of 18

Creating a Pull System in a Push Dominated Environment 6 A different approach Hotels provide check-out times They seem to have no issues Makes a case for early discharge 7 Early Discharge Hospitals quickly went to early discharges Reality batching patients Creating extra work for staff Hotels use check-in times As a result of these issues, many organizations began to look for new and better ways to perform. People began to look to other industries to find something that would help to alleviate the problems. The hotel industry was noted to be somewhat similar to hospitals, but yet handling their discharging much differently. Hotels also are a service industry that has an in- and out- flow of customers, as well as having housekeeping clean each room before the next customer. For years, hotels have been using a standard checkout time for the customers and it has enabled them to maintain better control of their population. The use of the checkout time has worked extremely well for hotels and seems to make a valid case for using it in healthcare as well. It appeared that if hospitals began implementing standard checkout, there would not be an issue of lack of beds for arrivals. As a result of this seemingly magic solution, hospitals quickly transitioned to utilizing Early Discharge times. The Health Care Advisory Board even suggested it to their members as a wonderful solution for solving the bed availability problem. Some hospitals would use mantras like Think Noon, or something similar. Across the nation hospitals began using the discharge times of 11am or noon. Unfortunately, what many organizations, ours included, failed to notice is that a standard early discharge time simply was batching patients. The result of this early discharge was extreme amounts of work for all staff. For a nurse, in addition to performing the morning medication pass, the nurse needed to ensure that patients scheduled for discharge that day were ready to go. Other ancillary staff (e.g. pharmacy, respiratory therapy, dietary, physical therapy) were also required to do everything in the morning. Once the patient is discharged, housekeeping is then tasked to clean all discharged patients rooms at the same time. Unaware of which beds will be filled first, the clean time for an unneeded bed may be at within one hour, but perhaps the bed that is needed sooner will not get cleaned immediately. It is also possible that the room might remain unused for hours after discharge. The key difference between hospitals and hotels is that T. Schneider, J. Allison Page 3 of 18

Creating a Pull System in a Push Dominated Environment hotels use standard check-in times. A standard checkin time is not feasible for the healthcare setting. Unfortunately, healthcare does not have that much control over their patient arrivals. 8 Benefits of Early Discharge Analyzed Discharge Process Nursing Staff involved Illustrated opportunity Now let s build off of the benefits The information presented thus far about early discharge is not to say that it is completely off base. The implementation of Early Discharge required many hospitals to analyze their entire discharge process. In order to meet the early discharge time, many organizations worked hard to ensure that the discharge process was as efficient as possible. Early Discharge initiatives also helped educate nursing staff about the impact of available beds on the flow of patients. This provided an opportunity at Tallahassee Memorial to begin educating nurses on system thinking and improving processes of discharge. The Early Discharge Initiatives also illustrated the opportunities to all levels of staff -- some patients do wait longer than necessary for discharge. A new concept is building off of the benefits of Early Discharge. In fact, it might be considered to be a variation of Early Discharge. T. Schneider, J. Allison Page 4 of 18

Creating a Pull System in a Push Dominated Environment 9 Flow Innovations Institute for Healthcare Improvement (IHI) Tom Nolan Roger Resar Carol Haraden Discharge Scheduling 10 Design Targets Percent of Discharges Scheduled 80% Percent of Scheduled Discharges meeting Actual Discharge Time 80% Financial Impact Before we discuss this variation of Early Discharge, I will provide some background about how this concept was formed. The Institute for Healthcare Improvement (IHI) invited our organization, along with 5 other institutions, to join a Flow Innovation team to participate in the Flow Design Initiative. IHI wanted to test some theories that they had about impacting the flow of patients through the healthcare setting. Tom Nolan, Roger Resar, and Carol Haraden are faculty members of IHI that have contributed greatly to the theories that are being tested to impact patient flow. It is through this collaboration with IHI that we were introduced to the concept of Discharge Scheduling. As a member of the Flow Innovation team, TMH was required to follow a fast-paced timeline. IHI provided the team members with certain Design Targets that needed to be met by December 31, 2003. If IHI felt that an organization was not moving at the pace needed, they reserved the right to request the organization drop out of the Innovation Team. The measures that we tracked and were expected to impact were: -Percent of discharges scheduled. The goal for this measure was 80% of all hospital discharges to be scheduled. Since this was a new concept for our organization, we were at 0% in June 2003. -Percent of scheduled discharges meeting actual discharge time. The goal for this measure was 80%. Meeting the scheduled discharge time included actual discharges that were within (plus or minus) 30 minutes of the scheduled time. -Financial impact. This is a measure that did not have a defined goal. It was expected that discharge appointments would positively affect hospital finances. T. Schneider, J. Allison Page 5 of 18

Creating a Pull System in a Push Dominated Environment 11 Design Targets Time of ED Admission Decision to floor 1 hour Number of Diversions 0 Actual Hospital Throughput -Time of Emergency Department admission decision until the patient was to the assigned floor. The goal for this measure was one hour. Our organization had a long way to go to reach that target. At the beginning of the study (June 2003) our value was nearly 6 hours. -Number of diversions. The goal for this measure was zero diversions. Due to the market our organization is in, we are not able to go on an official divert status. -Actual hospital throughput. There was not a defined goal for this measure. Again, it was expected that by implementing discharge appointments, hospital throughput would increase. 12 Other Industries Airline Trucking Manufacturing The Institute for Healthcare Improvement suggested that healthcare organizations begin looking to other industries, besides hotels, to learn about methods for discharges. One suggested example is the Airline industry. In the 1980s, it was not uncommon for airplanes to circle above airports waiting for a gate to open up. Perhaps you have noticed that airplanes do not frequently circle above airports today. The airline industry made an adjustment. Now planes will not take off until they have been assigned a slot at the destination airport. Above each gate, there is a clock that will count down minutes before plane arrival and minutes until plane take-off. This allows airport staff to ensure that all activities are complete by the time the clock reaches zero. Airports also serve people; people come in and out. Airports have planes arriving and taking off throughout the day. Can you imagine how hard it would be to make a connection if all planes departed by noon while arrivals continued to come in throughout the day? Another industry that was suggested for study was the Trucking industry. Granted, FedEx and UPS have very complex scheduling systems. However, some smaller trucking companies work hard to ensure that the appropriate trucks are available for the anticipated shipments. Trucking companies may have a number of different trucks and a number of different types of trucks. They work hard to ensure that the right truck is available at the right time. They use scheduling to T. Schneider, J. Allison Page 6 of 18

Creating a Pull System in a Push Dominated Environment ensure availability. An example that seems very fitting is a manufacturing example. Buzzwords have been moving through manufacturing environments over the past decades only to lead to the same concepts. Whether it Just-In-Time production or Lean Manufacturing, the goal is to increase productivity and decrease costs by eliminating wastes. Many manufacturers are performing continual lean implementations on their various production lines. 13 Lean Manufacturing Takt-based production One-Piece Flow Pull Production Source: Boeing, Inc. According to Boeing, a leading aircraft manufacturer, the three key Lean principles are Takt-based production, One-piece flow, and pull production. Takt-based production is a key principle of Lean Manufacturing, however it is not directly applicable to the discharge scheduling initiative. Takt-based production is using the customer demand to pace the manufacturing process. Takt is German for target. The takt time is determined based on the customer s rate of demand. By ensuring that all process meet the takt time, a company can ensure the needs of the customer are met timely. The second key principle of Lean Manufacturing, and a more applicable example is one-piece flow. Some organizations refer to this as make one, move one. One-piece flow is the opposite of batch and queue production. Utilization of one-piece flow improves quality and decreases cost. Early Discharge (out by noon) initiatives can be seen as batch production. Beds are emptied all at one time, only for them to wait to be filled. Discharge Scheduling, however, is similar to one-piece flow. Beds are emptied one at a time (or in small quantities) throughout the day. The third key principle of Lean Manufacturing is pull production. Pull production is closely related to onepiece flow. In pull production, products are only produced when requested by a customer. Instead of producing a number of parts in hopes of customer need, the production schedule is based on customer request. On a production line, products are passed from one process to another only when the following process needs another product. Pull production is the opposite T. Schneider, J. Allison Page 7 of 18

Creating a Pull System in a Push Dominated Environment push. Pull production requires communication to upstream and downstream processes. It is pull production that Discharge Scheduling is replicating. 14 Pull in Healthcare Requesting new patients Open beds before beds needed Many may think that although Lean Manufacturing concepts work great in manufacturing environments, it is virtually impossible to replicate these principles in the healthcare environment. Perhaps the most important Lean principle that Discharge Scheduling is replicating is Pull production. Although healthcare is not making products, it is possible to create pull in healthcare. The current situation in most healthcare organizations is that the Emergency Department will call with an admission, which forces a floor to discharge a patient to make room available. This is simply pushing patients from one area to another. The Emergency Department is pushing a patient to a floor. In turn the floor is pushing a patient home. In order to achieve pull in the hospital, floors need to get to the point where they are requesting patients from the Emergency Department or from other units. In order to do that, the floor needs to open beds by discharging patients before the bed is actually needed. T. Schneider, J. Allison Page 8 of 18

Creating a Pull System in a Push Dominated Environment 15 Discharge Patterns Percent of Discharges 12% 10% 8% 6% 4% 2% 0% Problem Area 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 Hour of Discharge Is it true that the current healthcare situation is a push system? It was definitely true at Tallahassee Memorial. The graph here is showing the discharge patterns of a certain floor. Notice that the majority of discharges are happening in the late afternoon. The late afternoon discharges are a result of patient, physician, and nurse preference. 16 Bed Needs Percent of Arrivals 14% 12% 10% 8% 6% 4% 2% 0% Need Area 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 Hour of Bed Need 17 Capacity and Demand Patient Flow Coordinator Bed Huddle meetings Discharge Slots Bulk of Discharges We then decided to look at when we really needed the beds. We were not able to pull the bed request time from our computer system as initially thought. Instead, the data was collected manually to determine what our bed needs were. What you see here are the times that our beds are needed most often. Notice that most beds are needed late morning or early afternoon. However, as noted by looking at the discharge times, the bulk of our discharges were happening at later times. This is why we had a push system. The Emergency Department, physician offices, and other units were pushing their patients when there weren t beds available. Obviously something needed to be done to better balance the capacity and demand. Our organization began utilizing three strategies to create a more predictable system. The first was the utilization of a Patient Flow Coordinator. The second was the use of Bed Huddle meetings. The third was the use of discharge slots. T. Schneider, J. Allison Page 9 of 18

Creating a Pull System in a Push Dominated Environment 18 Patient Flow Coordinator Facilitates Bed Huddle Rounds on Units/Floors 19 Bed Huddles 15 minute meeting 8:15 a.m. & 4:00 p.m. Multidisciplinary Nurse Managers/Charge Nurse Environmental Services Social Work & Utilization Management Bed Control Rehab Liaison The Patient Flow Coordinator was one of the first changes that was made. We realized the need to have someone to be the central authority on bed placement. A Nursing Supervisor s role was transformed into the Patient Flow Coordinator. The Patient Flow Coordinator is the facilitator of the Bed Huddle meetings. This person maintains a good working relationship with each of the units/floors. It is also the responsibility of the Patient Flow Coordinator to make continuous rounds to ensure that no beds are being hidden or that no patients are waiting too long for bed placement. The patient flow coordinator is charged with ensuring appropriate bed placement for all admitted or transferred patients. The second strategy that was used to create greater pull through the system was a Bed Huddle. The Patient Flow Coordinator soon realized that there needed to be better communication each day regarding unit activities. The Bed Huddle is a 10-15 minute meeting. These huddles take place twice each day, one in the morning at 8:15 a.m. and one in the afternoon at 4:00 p.m. The Bed Huddle meetings have representatives from all surgical and medical floors, including the ED. Generally the charge nurse or designee would be present. Also present at the huddles were Environmental Services, Social Work, Utilization Management, Bed Control, and a Rehab liaison. Environmental Services is able to get an understanding of where the hot spots will be for the day and can adjust staffing accordingly. Social Work and Utilization Management are able to obtain and report information about patients be transferred to other facilities. Bed Control is able to get a clear picture of where patients are and where they will be going. Because of this meeting, Bed Control has seen a significant decrease in the number of phone calls made each day. Also in attendance is a Rehab Liaison. This person is able to communicate the number of available beds at one rehabilitation facility as well as the anticipated times of transfer. T. Schneider, J. Allison Page 10 of 18

Creating a Pull System in a Push Dominated Environment 20 Bed Huddles Floors report: Staffed Beds Staffing for Each Shift Current Census Anticipated Discharges/Transfers Out Anticipated Admissions/Transfers In Surgery Schedule Reviewed Emergency Department Admissions Placed 21 Discharge Slots Arrival/Need Patterns Physician Preference Patient Preference At the Bed Huddle, each floor will report the number of staffed beds. The floor will provide the ideal number of staffed beds as well as the maximum number of staffed beds. They also report the current census, anticipated discharges or transfers out, and the anticipated admissions or transfers in. This is also the time when floors report which patients they have scheduled to leave that day. Also, at the morning Bed Huddle, the surgery schedule for that day is reviewed, and the patients on the schedule are placed to the appropriate unit. The Bed Huddle also consists of a representative from the Emergency Department. Any patients that are waiting for beds are assigned to a unit, as well as any predicted admissions. Originally the Bed Huddle was done separately for the Medical and Surgical Floors. However, the meeting time was so short that the Bed Huddle was expanded to have all units reporting at the same time. To create the Discharge Slots, we studied our arrival or need patterns. We utilized the data regarding bed request time to get a better understanding of when the beds were actually needed. We also allowed the physician to provide feedback regarding which time worked best for their schedules to see the patient the following day. Finally, we ensured that the patient was kept informed and that transportation could be arranged to meet the scheduled time. Some units found it effective to only offer set discharge slots. Other units offered set discharge slots with an other option. T. Schneider, J. Allison Page 11 of 18

Creating a Pull System in a Push Dominated Environment 22 Orchestrating Discharge Determine Day of Discharge Determine 24 hours in advance Utilize Pathway Data Assign Time of Discharge Discharge Slots One of the first key pieces of orchestrating the discharge is determining 24 hours in advance which patients are eligible for Discharge. Pathway average LOS data helped to give us a starting point in determining these patients. This knowledge was also gained through conversation with Physicians, reading progress notes, and communicating with the bedside nurse. Once it was determined which patients are possible for discharge, the time of discharge needed to be assigned. The best way to assign the time of discharge is the utilization of Discharge Slots. 23 Orchestrating Discharge Communication Unit Marker Board Physician Anticipation Form Bed Huddle The most difficult part of creating discharge appointments 24 hours in advance is the communicating the discharge to all affected parties. One of the most effective communication tools is the utilization of a unit marker board. Simply documenting the anticipated date and time of all patient discharges in a central place, provides other departments with a clear picture of what is happening in a given day on a unit. One of the methods that has been utilized to better understand the physician desires for patient discharge is the Physician Anticipation Form. The Physician Anticipation form is a small sticker that is placed on the front of each chart for the Physician to document the estimated date and time of patient discharge. This method is being tested on one unit. The effectiveness of this form has begun to decrease over the months. Compliance was good at first, but now very few are using the form. One of the other methods to relay information is the use of the daily Bed Huddles. T. Schneider, J. Allison Page 12 of 18

Creating a Pull System in a Push Dominated Environment 24 Extending the Chain Rehabilitation Center Utilize Discharge Slots Scheduling 70% of all Patient Discharges Liaison reports at Bed Huddle 25 Hospital Roll-out Small Tests of Change Summary of Testing Worksheet Unit by Unit 26 Financial Impact Reduction in Transfers Increase Appropriate Placement Decreased Length of Stay Especially in ICU, ED, PACU Increased Bed Utilization We have also done some work on extending the chain beyond our inpatient hospital side. We are also working with our Rehabilitation Center to help them decrease the variation in their day. Improving their processes has a positive effect on the hospital s ability to place patients. The Rehabilitation Center is utilizing set discharge slots. They have been scheduling 70% of all patient discharges 24 hours in advance. The Rehab Liaison is able to report times of available beds to the units at the Bed Huddle meeting. The Rehab Center has been able to fill empty beds more quickly by planning discharges one day in advance and planning admissions 2 hours after the scheduled discharge time. To roll-out the Discharge Scheduling initiative to all units, our organization is utilizing the small tests of change Plan, Do, Study, Act cycles. For each cycle we would test a new method or revamp an old method. We also maintained a Summary of Testing Worksheet that enabled us to ensure that we had a plan for the different functions of orchestrating the discharge. It helped to focus us on the areas where improvements were needed and were improvements were successful. In order to roll-out this concept, while simultaneously testing the concept, we went unit by unit. We started with a couple medical and a couple surgical floors. This enabled us to test a few strategies at one time. Although there are a number of satisfaction benefits for the patient, staff, and physicians, there are also some key financial measurements that we have tracked. One area of impact is a reduction in the number of transfers. This was achieved by increasing the percentage of patients placed in the appropriate bed the first time. The second area of impact is decreased length of stays. By better anticipating discharges, overall length of stays should decrease. More importantly, by selecting discharge slots based on actual bed needs, we are more able to pull patients from a higher cost center in a more timely fashion. For example, we are able to decrease the amount of time a patient waits in the ICU, Emergency Department, or in PACU for an inpatient bed. The final area of impact is the increased bed utilization. This measure is tougher to measure. However, by T. Schneider, J. Allison Page 13 of 18

Creating a Pull System in a Push Dominated Environment anticipating our discharges more accurately and planning discharges based on bed needs, our bed utilization should increase. 27 Transfers Percent of Transfers 25% 20% 15% 10% 5% 0% Apr May June July Aug Sept Oct Nov Dec Transfers Trend This graph represents the impact that the activities surrounding the scheduling of discharges 24 hours in advance and the communication in the Bed Huddle has had on the average number of Transfers each day. The data shown here is for one of our post-surgical units. This decrease in transfers is directly related to the unit receiving the appropriate patients. This unit is providing discharge appointments to patients and is planning for admission at the Bed Huddle each day. We have not yet seen an impact in our other units. 28 Transfer Finances Cost Housekeeping Nursing Report & Assessment Assuming $100 per transfer Decreasing 6 transfers/month Savings of $600 monthly $7,200 per year Transferring a patient more times than is medically necessary can be a costly process. Some of the costs associated with transferring the patient include housekeeping cleaning additional rooms, nursing staff giving report and doing assessments, and physically transporting the patient. Based on these assumed costs, we were able to assume that a transfer costs our organization $100. Since we have been able to decrease the average number of transfers, we have been able to equate this decrease in transfers to a monthly savings of $600. Annualized, this figure grows to $7,200. In addition to finances, appropriate placement will enable the patient to receive better quality care and will increase customer satisfaction. T. Schneider, J. Allison Page 14 of 18

Creating a Pull System in a Push Dominated Environment 29 PACU to Inpatient Bed Avg PACU minutes 120 110 100 90 80 70 60 June Wk1 June Wk4 July Wk3 Aug Wk1 Aug Wk4 Sep Wk3 Oct Wk2 Oct Wk5 Nov Wk3 The data on the chart shown here represents the total amount of time a patient spends in PACU from arrival after surgery until they are transferred to an inpatient bed. Notice the impact we have had on this value. 30 PACU Finances Decreased time in PACU PACU cost = $610 per day Saved 10 PACU minutes per Patient Saving $105 per day $38,325 per yr Increased capacity of PACU Increased surgical procedures This decrease in wait time results in the patient spending less time in the PACU. Our organization has a set cost per day for each unit of the hospital. Based on the cost per day of the PACU being $610, we are able to calculate estimated savings. In the past few months, we have shown a decrease of 10 minutes for each patient in the PACU. This improvement alone results in a savings of $105 per day, which annualized results in a savings of $38,325. This decrease also increases the capacity of the PACU which could increase the number of surgical procedures performed in one day, or decrease the number of cancelled or delayed surgeries due to lack of PACU beds. 31 Overall LOS 4 3.5 3 2.5 2 1.5 1 0.5 0 2A- Surg 5A- Med 3A- Surg Before Current This graph is showing the impact that these activities have had in the overall length of stay of patients on their respective medical or surgical floors. The units shown in this graph are some of our pilot units. Notice that there is a decrease in length of stay, but it does not appear to be overly significant. T. Schneider, J. Allison Page 15 of 18

Creating a Pull System in a Push Dominated Environment 32 Smoothing Discharges 14% Percentage of Discharges 12% 10% 8% 6% 4% 2% 0% 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Hour of Discharge Jun-03 Nov-03 This graph is showing the impact that the activities surrounding Discharge Scheduling has had on our discharge times. Through these efforts, we have hoped to smooth the number of discharges and provide a more predictable (less variable) environment. Notice the time of discharge has only slightly shifted towards the time of bed need. 33 Scheduled Discharges Percent Scheduled 80% 70% 60% 50% 40% 30% 20% 10% 0% June July Aug Sept Oct Nov Dec This graph is showing the percentage of discharges scheduled each month. Before beginning with IHI we were not formally scheduling any of our discharges. As the graph shows, we were unable to reach the 80% suggested by IHI. In fact, we have been struggling to find the success needed to bring us past our pilot units. 34 Lessons Learned All floors/units are different Start with Surgical Units Utilize Nurse Champions Communication is key Throughout the testing and implementation stages, we have learned a number of new lessons. One lesson learned was that all areas are different. The solution for one unit may not work on another unit. Different staff, different physician groups, and different patient populations require tailored solutions. The second lesson that we learned is that you should start with surgical units. Surgical units tend to be more predictable. Discharges are less frequently delayed on surgical units than on medical units. Not only should it be easier to implement, but also it should be easier to learn from. The third lesson we learned is that the utilization of Nurse Champions (and physician champions) is important. This is especially true on units were the Nurse Manager is inadequate or overwhelmed. The nurse champions can work to spread the successes to other nurses. The forth lesson T. Schneider, J. Allison Page 16 of 18

Creating a Pull System in a Push Dominated Environment we learned is that communication is key. There needed to be a way to communicate to other disciplines. Everyone who interacted with that patient needed to know the scheduled discharge time. Sometimes this was electronic or written, other times it was verbal. Another aspect of communication is nurse to physician communication. It may be helpful to create a script for the nursing staff to ask the physician about anticipated discharge date and time. 35 Lessons Learned Anticipating discharges is difficult Prediction can be a constraint Begin with Slots Document & Understand Variances Another lesson we learned is that anticipating discharges is more difficult than we anticipated. In fact, even some surgical floors were having a hard time anticipating the day of discharge. We also learned is that the prediction piece of discharge scheduling can easily become a constraint. As a result, we put more emphasis on spreading the discharges throughout the day (as needed) by utilizing the discharge slots. From this effort, we learned that placing patients into slots is less scary than anticipating 24 hours in advance. Many nurses and staff were worried that they would be incorrect when scheduling discharges 24 hours in advance. By placing patients in slots, it is encouraged to place the patient 24 hours in advance, but if the placement occurs the morning of discharge, the system is still predictable. Finally, we learned that the most important piece of early trials and implementation is documenting and understanding variances from the schedule. Understanding why a patient did not make the scheduled appointment time enables valuable changes to be made. It helps understand if it s a nursing delay, ancillary delay, physician delay, or family/patient delay. T. Schneider, J. Allison Page 17 of 18

Creating a Pull System in a Push Dominated Environment 36 Next Steps Increase appointment reliability Investigate Smoothing Elective Admissions Separating Flow of Emergency and Add-on Cases Begin linking admissions to discharges Although we have come a long way since late June, there is still much work to be done. We need to continue working to increase the reliability of our appointment times. We also need to investigate smoothing our elective admissions. Looking at the standard deviation of our Emergency Department admissions and our Elective surgical admissions made an interesting comparison. From this comparison, it was noted that day-to-day, our Emergency Department was more predictable than our surgical schedule (something that we can control). One concept that is currently being tested by other facilities is separating the flow of Emergency and add-on procedures. Finally, to truly perform the pulling piece of all of this, we need to begin looking to link admissions to our daily discharges. 37 Questions? Tallahassee Memorial HealthCare T. Schneider, J. Allison Page 18 of 18

Creating a Pull System in a Push Dominated Environment Todd Schneider, Improvement Advisor Julie Allison, Project Manager Tallahassee Memorial HealthCare

Background Tallahassee Memorial HealthCare 770 licensed beds 24,000 annual inpatient admissions 67,000 annual Emergency Dept visits Recipient of the Pursuing Perfection: Raising the Bar for Healthcare Improvement grant from RWJF IHI Flow Innovation team member Tallahassee Memorial HealthCare

Outline Transition from Early Discharge to Discharge Scheduling Lean Healthcare = Discharge Scheduling Methods to facilitate change Financial Impact of Changes Next Steps

Healthcare Realities Emergency Department visits are increasing Reimbursements are decreasing Healthcare organizations are struggling to remain profitable

What s Constant? Emergency Department admissions Direct admissions from MD office Beds unavailable when needed Numerous afternoon discharges

A different approach Hotels provide check-out times They seem to have no issues Makes a case for early discharge

Early Discharge Hospitals quickly went to early discharges Reality batching patients Creating extra work for staff Hotels use check-in times

Benefits of Early Discharge Analyzed Discharge Process Nursing Staff involved Illustrated opportunity Now let s build off of the benefits

Flow Innovations Institute for Healthcare Improvement (IHI) Tom Nolan Roger Resar Carol Haraden Discharge Scheduling

Design Targets Percent of Discharges Scheduled 80% Percent of Scheduled Discharges meeting Actual Discharge Time 80% Financial Impact

Design Targets Time of ED Admission Decision to floor 1 hour Number of Diversions 0 Actual Hospital Throughput

Other Industries Airline Trucking Manufacturing

Lean Manufacturing Takt-based production One-Piece Flow Pull Production Source: Boeing, Inc.

Pull in Healthcare Requesting new patients Open beds before beds needed

12% 10% 8% 6% 4% 2% 0% Discharge Patterns Problem Area 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 Hour of Discharge 0:00 Percent of Discharges

20:00 22:00 14% 12% 10% 8% 6% 4% 2% 0% Bed Needs Need Area 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 Hour of Bed Need Bulk of Discharges 2:00 0:00 Percent of Arrivals

Capacity and Demand Patient Flow Coordinator Bed Huddle meetings Discharge Slots

Patient Flow Coordinator Facilitates Bed Huddle Rounds on Units/Floors

Bed Huddles 15 minute meeting 8:15 a.m. & 4:00 p.m. Multidisciplinary Nurse Managers/Charge Nurse Environmental Services Social Work & Utilization Management Bed Control Rehab Liaison

Bed Huddles Floors report: Staffed Beds Staffing for Each Shift Current Census Anticipated Discharges/Transfers Out Anticipated Admissions/Transfers In Surgery Schedule Reviewed Emergency Department Admissions Placed

Discharge Slots Arrival/Need Patterns Physician Preference Patient Preference

Orchestrating Discharge Determine Day of Discharge Determine 24 hours in advance Utilize Pathway Data Assign Time of Discharge Discharge Slots

Orchestrating Discharge Communication Unit Marker Board Physician Anticipation Form Bed Huddle

Extending the Chain Rehabilitation Center Utilize Discharge Slots Scheduling 70% of all Patient Discharges Liaison reports at Bed Huddle

Hospital Roll-out Small Tests of Change Summary of Testing Worksheet Unit by Unit

Financial Impact Reduction in Transfers Increase Appropriate Placement Decreased Length of Stay Especially in ICU, ED, PACU Increased Bed Utilization

Apr 25% 20% 15% 10% 5% 0% Transfers Transfers Trend July Aug Sept Oct Nov Dec June May Percent of Transfers

Transfer Finances Cost Housekeeping Nursing Report & Assessment Assuming $100 per transfer Decreasing 6 transfers/month Savings of $600 monthly $7,200 per year

PACU to Inpatient Bed 120 110 100 90 80 70 60 June Wk1 June Wk4 July Wk3 Aug Wk1 Aug Wk4 Sep Wk3 Oct Wk2 Oct Wk5 Nov Wk3 Avg PACU minutes

PACU Finances Decreased time in PACU PACU cost = $610 per day Saved 10 PACU minutes per Patient Saving $105 per day $38,325 per yr Increased capacity of PACU Increased surgical procedures

Overall LOS 4 3.5 3 2.5 2 1.5 1 0.5 0 2A- Surg 5A- Med 3A- Surg Before Current

14% 12% 10% 8% 6% 4% 2% 0% Smoothing Discharges Jun-03 Nov-03 Percentage of Discharges 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Hour of Discharge

Scheduled Discharges Percent Scheduled 80% 70% 60% 50% 40% 30% 20% 10% 0% June July Aug Sept Oct Nov Dec

Lessons Learned All floors/units are different Start with Surgical Units Utilize Nurse Champions Communication is key

Lessons Learned Anticipating discharges is difficult Prediction can be a constraint Begin with Slots Document & Understand Variances

Next Steps Increase appointment reliability Investigate Smoothing Elective Admissions Separating Flow of Emergency and Add-on Cases Begin linking admissions to discharges

Questions? Tallahassee Memorial HealthCare