Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months

1. Increasing ED and Hospital CapacityTop Initiatives for Dramatic Results in 6 Months Presented by Michael B. Hill, MD, FACEP January 10, 2003 “On Our Watch” Illinois College of Emergency Physicians

2. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

3. Why Don’t Hospitals and EDs Work?

4. Barriers to Top ED Performance • Caregivers have unclear vision on how to meet conflicting needs of emergency and unscheduled medical care • Most EDs are not set up to deal with predictably unpredictable arrival times of ED patients. • Organizational culture is one in which we do not ask for help: • Unclear when to do it • Unsure who to ask • Variable response to request

5. Barriers to Top ED Performance • Variable integration of ED operation with inpatient delivery systems • Varying degrees of sophistication in defining operational metrics • ED as significant revenue driver is not articulated/understood by key constituencies.

6. Key Finding Confirms Central Challenge to Hospital Capacity Issues • Bottom quartile performance for key operational tasks that affect inpatient intake/discharge and ED performance: • Explains heavy resource utilization • Indicates unclear ownership, accountability, lack of operational metrics, significant process and unit variability, and lack of backup systems

7. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

8. Traditional Approach for Improvement • We’ll fix the ED if you give us more: • Space • Staff • Information technology • We can’t fix our ED due to: • Demographics of our population • Unpredictable volume surges

9. Traditional Change Process Initiation Based on Tactical Initiatives • Testimonial • Anecdote • Manager has an idea • Strategic initiative – rare

10. Why ED Physicians Think of Solutions as Tactical Initiatives • Primary tool we use for CQI • Does not require hospital leadership buy-in or approval. • Minimal budgeting impact. • Few resources to identify desired behavior.

11. Major Problems with Tactical Initiatives • Leadership not brought into process prior to implementation • Not enough resources to: • Develop solution • Communicate solution • Inspect to ensure proposed change is actually completed • Staff not brought into development process • No measurement systems • No inspection for desired behaviors

12. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

13. Team Based Care • Assign hospital and unit ownership and accountability • Give tool sets and skills to owner for success • Use multiple processing units • Reduce set up / start time • Deliver staff consistently • Set up real time communication system

14. Metrics Driven Management • Develop operational definitions and goals • Reach agreement on expectations. Then hold managers and staff accountable • Monitor data on a weekly basis – database management • Give people access to the data • Hard wire specific next step activities based on results

15. Major Problems with Metrics • Key performance indicator identification • No defined targets • Acuity selection • Removing outlier data • Start / stop points • Sample size • Ownership not identified

16. ED KPIs and Owners

17. Inpatient KPIs and Owners

18. Reduce Cycle Time Achieving target goals by: • Moving from push to pull systems • Being absolutely ruthless in eliminating variation • Defining clear transition steps from each provider to the next • Delivering work consistently • Defining time expectations for common task completion • Hard wiring triggers and backup systems

19. Push Systems – Scope of the Problem • Current process owner responsible to get patient to next step • Individual ownership encourages innovation, negotiating skills and rewards variability • Variability in task accomplishment means that most tasks are sequential • High utilization of resources required to complete tasks • Predictably breaks down when busy due to lack of defined back up system • Almost all hospital intake and discharge systems are “push” systems

20. Pull Systems – Why We Want Them! • Next Step process owner responsible to ensure patient receives next step • Defined expectations of other staff decreases variability and encourages consistency (“hand off”) • Decreased variability allows parallel processes to stabilize • Processes keyed to Key Performance Indicators ensure consistent work effort regardless of census • Well defined backup systems can tolerate volume surges • Top performing hospitals use “pull” systems

21. Learning Organization • Explicit training and orientation program • Performance evaluation explicitly link constituency specific behavior to key performance indicators

22. Stakeholder Loyalty • Passionate, single mindedness to customer outcomes • Achieve target goals

23. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Healthcare Change – How to Design Change

24. We’ve Tried to Fix the ED Before And … Bad News: • Tactical initiatives rarely create signifi-cant overall length of stay improvement.

25. Even Successful Tactical Initiatives Do Not Have Great Success – The ED Perspective Ease of SuccessImplementation Charge Nurse runs the ED A D Team Based Care A- D Inpatient Admission Ownership B+ D- Scribes B C Fast Track B C Physician Compensation System B- D Match Capacity to Demand B- D Bedside Registration B- D Observation Unit C- D

26. Tactical Initiatives That Require Evaluation • ED Mini Lab • Dedicated Lab Phlebotomist • Dedicated Radiology Technician • Patient Tracking Systems • Additional Staff • Additional Space

27. Problems with Traditional Approach to ED Overcrowding • Most ED efforts traditionally focus on tactical initiatives that ED has traditionally acknowledged control over • No single tactical initiative appears to create significant ED LOS improvement on its own • Success in reducing ED LOS or ambulance diversion appears to be related to multiple, simultaneous initiatives that focus on defined backup systems for common processes

28. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

29. Is the ED the Actual Problem? ED crowding is actually one of several symptoms of hospital inpatient capacity issues. • ED Overcrowding • Direct Admission Process • Critical Care Intake and Transfer to Floor • PACU Transfer to Floor • Surgery Scheduling

30. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

31. Why Is It Hard to Fix theInpatient Admission Process? – The Bad News • Inpatient admissions are inexorably linked to both: • Inpatient discharge process • Movement of patients from floor to floor • No clear ownership of any of these sub-processes • No clear organized operations knowledge base to start from

32. Tactical Initiatives for Hospital Admission • Ease of EfficacyImplementation • Roles & Responsibility • Hospital Change Nurse A C- • Unit Charge Nurse A C- • 3 Bed Ahead System A C+ • Key Bed Process Automation A- B- • High Census Bed Protocol B+ D • Constrain Inpatient Bed Demand B- D • Change of Shift Overrides C+ D • EDMD Admit Privileges D+ D- • Bed Control in ED D- B

33. Key Opportunities to Increase Inpatient Capacity–Moving From “Push” to “Pull” • Increase Inpatient Capacity • Augment bed control/admission process • Intake and Discharge Process Redesign • Develop Metrics system to measure operational performance and provide feedback to staff and leadership for intake and discharge process • Integration of IT for key processes

34. Increase Capacity of Inpatient Bedsby Constraining Demand • Create dedicated outpatient area for short-stay patients and outpatient procedures, rather than utilizing inpatient beds • Discharge patients earlier in the day in a more consistent fashion to decrease discharge/ admission mismatch • Formal multidisciplinary rounds to evaluate any patient in hospital greater than 15 days.

35. Aligning Bed Identification Process - Moving from “Push” to “Pull” System • Formalize hospital ownership of all intake/ discharge activities • “Hospital Administrative Supervisor” • Formalize unit responsibility for pre-planning “bed ahead” system • Automation of key processes • Bed request/notification system • Hospital bed activity status with intake/discharge activity, KPIs, and staffing • Capacity simulation modeling to predict bed/staffing needs using information from intake/discharge data to predict bottlenecks

36. Communication Systems: Real Time Notification of Work Effort and Capacity Bed Tracking – implement a bed tracking system that allows bed availability status to be monitored by Bed Control and Charge Nurse with the following notification capabilities: • Pending/actual • Discharge cleans • Open beds • Pending discharge/transfer activity • Occupied beds • Staffing • Key performance indicator

37. Aligning Bed Identification Process - Moving from “Push” to “Pull” System • Obtain ETA on new patients • Monitor time to arrival with Bed Control notification if receiving unit observes delay • Develop bed cancellation policies • Formal inpatient diversion notification system • Bed control meeting with hard wired action plan • Pre-plan critical care and step-down transfers to floor and telemetry removals 12 hours prior to transfer • Formalize high census protocol with defined electronic hospital and medical staff notification of desired work effort

38. Align Intake Process-Moving from “Push” to “Pull” System • Bed Control gives bed assignment and ETA to receiving unit • Sending unit gives ETA with report • Formal pre-planning prior to patient arrival • Formal greeting, order placement and order initiation • Formal monitoring and communication of new workload

39. Aligning Discharge Process-Moving from “Push” to “Pull” System • Formal assignment of discharge process ownership for all patients • Formal pre-planning 2 days prior to discharge of key nurse and care coordinator discharge activities • Formalize evening pre-planning of discharge review • Formalize time of discharge for patients and pre-plan for estimated time of discharge • Formalize patient/family communication about method and time of discharge

40. Aligning Ancillary Service Process • Adjust housekeeping hours to match discharge demand • Formal pre-planning of discharge activities with Charge Nurse for each shift • Preplan at least 50% of transportation needs • Prioritize category of “potential discharge” for lab and radiology

41. Aligning Medical Staff Work Process • Constrain Demand • Utilize alternative hospital source for short stay/outpatient procedures • Discharge patients earlier in the day in a maximum consistency fashion to decrease discharge/admission mismatch • Intake • Utilize primary contact for all incoming patients to either Admitting or to ED • Time/date orders legibly • Provide ETA on new patients • Orders accompany patient prior to arrival on floor

42. Aligning Medical Staff - Discharge Process • Standardize predischarge planning procedures and tools • Pre-plan discharges 2 days out • Formal communication on evening prior to discharge • Use of “potential discharge” category for lab/radiology tests needs by 0730 • Round by 0745 on potential discharges • Lab/radiology test results on chart • Review potential discharges as first step of morning rounds • Initiate timed discharge orders prior to 0900 with conditional orders

43. Overview of Presentation • Scope of the Problem • Traditional Approach to ED Crowding • Key Concepts in Capacity Redesign • Tactical ED Capacity Solution • Relationship of ED Overcrowding to Inpatient Capacity • Tactical Inpatient Capacity Solution • Healthcare Change – How to Design Change

44. How to Organize a Plan to Decrease Length of Stay • No magic bullet. • Focus on key multiple key sub-processes. • Develop organized plan which includes: • Resources to perform analysis, recommend changes and then implement changes • Communication plan • Assessment methodology • Measurement system

45. Key Reference:Diffusion of Innovations,Everett Rogers (1962, 1983, 1995) Diffusion: the process by which an innovation is communicated through certain channels over time, among the members of a social system. Includes both spontaneous and planned spread.Innovation: an idea, practice, or object that is perceived as new by an individual or other unit of adoption.

46. Hospital Clones Diffusion Process

47. The “Diffusion Curve” “tipping” point”

48. The “Tipping Point” “The name given to that one dramatic moment in an epidemic when everything can change all at once.” - M. Gladwell “The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often impossible to stop the further diffusion of a new idea, even if one wished to do so.” - E. Rogers

49. Adopter Categorization: Speed of Adoption Early Majority Late Majority PAT Members Mentors Early Adopters Resistors (Traditionalists) 2% 13% 35% 15% 35%

50. Successful Spread – How to Manage It Variables affecting the rate of adoption • Attributes of the change • Type of decision • Communication channels • The social system • Promotional efforts • Change attributes that affect adoption • Relative advantage (evidence from testing) • Compatibility with current system (structure, values, practices) • Simplicity of the change and transition • Testability of the change • Ability to observe the change and its impact