section xiii capacity management / throughput

Section XIIICapacity Management / Throughput

Summary of Recommendations• Assessment Methodology • Observations of Patient Throughput Processes• Common ThemesAssessment and Recommendations• Case Management and Nursing • Ancillary Services • Bed Assignment• Emergency DepartmentImplementation Plan and Methodology• Patient Throughput and Capacity Management – Next Steps• Patient Throughput Optimization – Implementation Plan – Phase 1

– Phase I: Case Management/Social Work– Phase I: Bed Control/Nursing Supervisors

• Patient Throughput Optimization – Implementation Plan – Phase 2– Phase II: Inpatient Nursing – Phase II: Ancillary Services

• Patient Throughput Optimization – Implementation Plan – Phase 3– Phase III: Emergency Department

• Financial Impact• Key Components for Success

University of North Carolina Health Care SystemSection XIII –

Summary of Recommendations

Case Management• Reorganize Case Management/Utilization Review/Social Work/Pre-Auth to report to one Director.• Shift current Case Management model from a UR focus to a Care Coordination focus.• Determine service-specific needs for rounding practices that support discharge planning needs for

patient population.• Develop communication systems involving all care givers and family in coordination of patient

discharge.• Evaluate post-acute placement needs quickly during patient stay and communicate to the patient

and family the importance of planning for the post-acute care.• Implement processes during evening resident rounds to capture patients for anticipated discharge

the next morning – flag these patients to be discussed first during am teaching rounds, and encourage physicians to write orders during rounds.

• Implement clinical roadmaps for key high-volume DRGs.• Collaborate with physician leadership to improve outlying LOS with physician report cards.



Nursing• Establish Patient Throughput Steering Committee to meet on a bi-weekly basis, at a minimum, to

hear reports from front-line management involved in the patient throughput initiative and to discuss roadblocks and action plans.

• Determine official “Discharge Time” – most effective time should be before noon – and communicate expectations to all caregivers, patients and families.

• Reorganize daily “Bed Meeting” to plan for all admissions including surgical volume, cath lab procedures that convert to inpatients, clinic patients, Emergency Department admissions, etc.

• Implement accountability systems to include bed management metrics on each nursing unit and with all services that support patient movement.

• Define and implement incentive program to identify beds quickly at the front-line staff level.• Implement “day before discharge” notice program on all nursing units and develop accountability

systems to measure use of program.• Implement special flagging of lab tests, diagnostic procedures, and other support services for

improved response time for patients pending discharge.• Evaluate options for enhancing patient flow and proper utilization of Extended Stay Recovery Area,

Observation Unit, Clinical Decision Unit and specific discharge area for post-partum patients.



Ancillary • Laboratory

– Project capacity of phlebotomist draws based on current staffing and collection times.– Implement special flagging of lab tests for improved response time for patients pending

discharge.– Document and trial a “best practice” phlebotomy collection run.

• Radiology– Project capacity for each section based on current staffing and equipment.– It is necessary for IT to support a special flagging of diagnostic procedures in Lab and

Radiology for pre-discharged patients to improve response time for pending discharges.– Analyze no-show, add-ons, cancellations, I/P, OP, ED, walk-ins and scheduled patients by

day for trending.• Environmental Services

– Implement discharge notification system in all areas to allow prioritization of patients.– Assess staff understanding and compliance of the bed notification and cleaning process.– Implement quality, service, and cost measurement and reporting system.

• Transport– Negotiate with external customers on expectations of service; measure and report frequently.– Develop and assign specific downtime duties.



Bed Assignment• Define specific role for “Patient Flow Coordinator” to oversees all bed requests. • Redefine roles and responsibilities of bed assignment team.• Implement one large “Bed Board” to visualize all beds in the hospital simultaneously – begin with

a manual magnetic bed board before progressing to a more sophisticated electronic system.• Implement “one-call” system for physicians to call for direct admission of patients into hospital.• Develop process to plan for bed assignment needs using “Future Scheduled Admissions”

information in SMS.• Define and implement incentive program to identify beds quickly at the front-line staff level.• Pursue opportunities to align supply and demand of beds by service.Emergency Department• Engage key physician leaders in addressing the physician practice delays in the ED.• Develop a strong senior management message around the sense of urgency in improving patient

throughput and the role it will play in solidifying the future of UNC Hospital.• Develop and implement a core set of performance metrics and targets to increase awareness and

accountability around the patient throughput process.• Implement an organization-wide “trigger system” with clear action expectations for each patient

throughput process stakeholder during high census days and periods of ED overflow.• Conduct a detailed analysis of ED volume trends and the feasibility of utilizing the Peds ED area

as an alternate care setting to enhance patient flow.


Assessment Methodology

• Face-to-face interviews of key stakeholders in patient throughput processes• Observation of processes that impact patient throughput• Data collection and analysis

Assessment

Financial Technical CulturalTargets

Budget

Long-range Plan

Reports

Management Tools

Systems

Leadership Effectiveness

Communication Methods

Cultural Strengths


Observations of Patient Throughput Processes

• Nursing supervisor staffing meeting at 9:00 AM and 5:30 PM.• Patient discharge processes on various nursing units.• Day shift nursing report.• Day shift Charge Nurse report.• Health Unit Coordinator (HUC) and RN taking off patient orders (stat, d/c, routine).• Request for new admission process.• Multidisciplinary discharge meeting on various nursing units.• Environmental services rounds.• Bed assignment processes from bed request to official bed assignment.• Patient Transport process for a discharged patient.• Interdisciplinary rounds with various services.• Emergency Department patient flow from triage through to disposition and discharge.• CT and MRI patient flow and scheduling processes.• Laboratory drawing processes during critical early morning hours.• Inter-departmental communication methods.


Patient Throughput is a Continuous Cycle

PatientThroughput

Cycle

DischargePlanning

MD order to Discharge

Communicationof Actual

Discharge

Bed Turnaroundby Housekeeping

Decision to Admit

Registration/Bed Mgmt/

Authorization Communicate to Send/Receive

Areas

Patient Placement to Bed

Financial Verification

ActualPatient

Discharge


Patient Throughput Interdependency

Social Workers RN Bed Managers

RN Case Managers

Admitting/Financial Reps

Communication

RN/Charge RN

Communication

Com

mun

icat

ion

Com

munication

EV Services

Ancillary ServicesPhysician/PA


Patient Throughput Structural Design

Discharge Process

Bed ManagementProcess

PlanningComponent

ExecutionComponent

Turnover /Bed Cycle

Assignment /Patient

Placement

Meaningful and measurable performance metrics

Structured and streamlined communication


Common Themes

• Workarounds for patient placement results in off-service patients on many units throughout the hospital, e.g., dialysis patient will be on a general medical floor.

• Lack of a consistent message for patient throughput, particularly as it relates to a discharge process and an official “discharge time.”

• No sense of urgency for discharging patients early in the day.• Rounding practices do not support an early patient discharge.

[Portions of this page are confidential and have been redacted.]

Case Management and Nursing – Assessment

Discharge Process

PlanningComponent

ExecutionComponent

[Portions of the Assessment are confidential and have been redacted.]


University of North Carolina HospitalDischarges by Time of Day

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300

# of

Dis

char

ges

Discharges

September 20 -26, 2004


University of North Carolina Hospital NSICU Patient Flow for Transfers Out

900 1100 1300 1500 1700 1900

Patient A

Patient B

Patient C

Patient D

Time from order written to bed assigned Time from bed assigned to patient moved

Goal is to have a bed assignedwithin 15 minutes of notification

and transfer a patient within1 hour of receiving the bed


University of North Carolina Hospital 3 West “Cold Bed Study”

800 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000 3200

Ideal

32121

32011

32171

32341

32331

32071

32061

32341

32072

32122

Time from Order to D/C Time from D/C to Assigned Time from Assigned to Occupied

Goal is to d/c within 2 hours of order,respond to routine clean within 30 minutes,

average room clean is 30 minutes, thenmove new patient in within 1 hour of

assignment


University of North Carolina HospitalSample Quality Metrics

INDICATORS

Area Indicator Definition Standard Frequency

Floors Discharge within 2 hours of the order

Discharges will be complete within 2 hours of the written order 2 hours Daily

Floors % of Discharges out by 11 am

Comparison of the number of discharges out by 11 AM and total discharges 11 am Daily

Floors Admission Time Admissions will be accepted to the unit within 1 hour of notification 1 hour Daily

Floors Transfer Turnaround Time

Transfers will be complete within 1 hour of notification 1 hour Daily

Environmental Bed Cleaning Turnaround Time

Measuring the time from notification of needed cleaning to actual start of cleaning 30 minutes Daily

Environmental Stat Bed Cleaning Measuring the time from notification of needed cleaning to actual start of cleaning 15 minutes Daily

PACU Excessive Stay Measuring the time from patient ready to leave PACU until actual transfer time Daily

ED Excessive stay Measuring the time from patient ready to leave ED until actual transfer out time Daily


University of North Carolina Hospital3 West Quality Metrics

% of Patients D/C by 11 am

7.7% 8.3%0.0%

40.0%

0.0%0%

20%

40%

60%

80%

100%

9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004

% of Patients D/C by 11 am Target



% of Patients D/C within 2 hours of Order

30.8%

41.7%

25.0%

70.0%

50.0%

0%

20%

40%

60%

80%

100%

9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004

% of Patients D/C within 2 hours of Order Target



% of Patients Transferred Out within 1 hour

50.0%

33.0%

100.0%

0.0% 0.0%0%

20%

40%

60%

80%

100%

9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004

% of Patients Transferred out within 1 hour Target



% of Patients Transferred In / Admitted within 1 hour

27.3% 25.0%16.7%

45.5% 42.9%

0%

20%

40%

60%

80%

100%

9/22/2004 9/23/2004 9/24/2004 9/25/2004 9/26/2004

% of Patients Transferred in / Admitted within 1 hour Target



Orders by Service

0

5

10

15

20

25

Fam Med A Med B Med E Med G Med K Med W0%

20%

40%

60%

80%

100%

# D/C # of Orders % of Orders by 11 am

Main Admitting Services for 3 West


Case Management – Recommendations

• Reorganize Case Management/Utilization Review/Social Work/Pre-Auth to report to one Director.• Shift current Case Management model from a Utilization Review focus to a Care Coordination

focus.• Evaluate current role of CM in the ED and implement changed to ensure most efficient use of this

resource.• Identify and hire VPMA as a “Physician Champion” to support care coordination efforts and

interface with physician groups.• Determine service-specific needs for rounding practices that support discharge planning needs for

patient population.• Develop communication systems to involve all care givers and family in coordination of patient

discharge.• Evaluate post-acute placement needs as soon as possible during the patient stay and

communicate to the patient and family the importance of planning for the post-acute care.• Evaluate feasibility of Hospitalist program to enhance timeliness of patient care.• Implement processes during evening resident rounds to capture patients for anticipated discharge

the next morning – flag these patients to be discussed first during AM teaching rounds, and encourage physicians to write orders during rounds.

• Determine best methods for daily communication to patients and families regarding anticipated day of discharge and discharge needs -begin communication on the first day of a patient’s stay.

• Implement clinical roadmaps for key high volume DRGs.• Collaborate with physician leadership to improve outlying LOS with physician report cards.


Case Management Model

• All areas report to one director.• Implement VPMA role to support CRM.• Case Manager role.

– Utilize RNs as Case Managers.– Divide services or geographic units based on needs.

• 1 Case Manager per 25 to 30 patients.– Each Case Manager would be responsible for all aspects of the patient coordination.

• Utilization review of all new admissions.• Review every three days and as requested by payer.• Utilize Interqual criteria as a basis in determining LOS. • Initiate discharge planning on day of admission.• Coordinate discharge needs with Social Worker.• Manage cases as determined by medical condition.• Appropriate placement of patients on the front-end.

• Dedicated Case Managers to be responsible for coding and documentation support.• Social Workers continue to manage all psychosocial needs and discharge needs.

– 1 Social Worker per 30 to 40 patients.• Clerical support would be utilized for faxing, calling and coordinating paperwork.• Transition to a Case Management Model with a Resource Center.


Nursing – Recommendations

• Establish Patient Throughput Steering Committee to meet on a bi-weekly basis, at a minimum, to hear reports from front-line management involved in the patient throughput initiative and to discuss roadblocks and action plans.

• Determine official “Discharge Time” – most effective time should be before noon – and communicate expectations to all caregivers, patients, and families.

• Reorganize daily “Bed Meeting” to plan for all admissions including surgical volume, cath lab procedures that convert to inpatients, clinic patients, Emergency Department admissions, etc.

– Meeting should be limited to 15 minutes.– Meeting should occur each am, shortly after physician rounds.– Emergency bed meetings should occur when there is the possibility of refusing admissions.

• Implement accountability systems to include bed management metrics on each nursing unit and with all services that support patient movement.

• Define and implement incentive program to identify beds quickly at the front-line staff level.• Implement “day before discharge” notice program on all nursing units and develop accountability

systems to measure use of program.– Work with physicians to establish unit specific expectations.

• Implement special flagging of lab tests, diagnostic procedures, and other support services for improved response time for patients pending discharge.

• Evaluate the following options for enhancing patient flow and proper utilization of such units –Extended Stay Recovery Area, Observation Unit, Clinical Decision Unit.

• Evaluate need for specific discharge area for post-partum patients.

Ancillary Services – Assessment

Discharge Process

ExecutionComponent


Turnover /Bed Cycle



Ancillary Support – Radiology

4

6

16

1 1 1 1 1

3 3 3

7

3 3 3 3

0

4

8

12

16

20

CT MRI US MammoScreening

MammoDiagnostic

Fluoro Nuc Med PET

Day

s

Days to First Available Appointment Industry Standard



MRI Days to first Available Appointment - Outpatient

Increased efficiency with outpatient scheduling may

impact inpatient cases12

15 15

13

11

9 9

6

9

7

9

6

15

7

16

18

1415

12

89

1110

8

1514

12

15

12 12 12

6

8

10

54

0

4

8

12

16

20

'7/27 8/2 8/10 8/17 8/23 8/30 9/7 9/13 9/17 9/27 10/4 10/11

Day

s

Inhouse MRI ACC MRI SedationsSource: Scheduling Delays Report received from Radiology



Ultrasound - Days to First Available Appointment

The increase in US volume may start impacting inpatient flow due to the fact

that inpatients are slotted in open areas around the outpatients

3 3

8

5 53

8

54

8

1416

0

4

8

12

16

20

'7/27 8/2 8/10 8/17 8/23 8/30 9/7 9/13 9/17 9/27 10/4 10/11

Day

s

Days to First Available AppointmentSource: Scheduling Delays Report received from Radiology


3 3 3

1

0

0.5

1

1.5

2

2.5

3

3.5

CT MRI US Diagnostic

Hou

rs

IP Average Response Time


Source: Interviews with Management and Area Supervisors

Inpatient Response Time From Requisition to Start of Exam

Need to determine by nursing unit reasonable expectations to allow for optimal inpatient flow


Ancillary Support – Lab

Source: OP wait time received from lab

Outpatient Wait TimesMain Hospital*

0%

20%

40%

60%

80%

100%

Jan Feb Mar Apr May Jun% o

f pat

ient

s w

aitin

g <1

5min

from

ar

rival

tim

e



Source: Result Turn Around Reports received from lab Includes all sites but excludes Urinalysis and Troponin

Routine Test Turn Around Time

0%

20%

40%

60%

80%

100%

Jan Feb Mar Apr May Jun

% o

f rou

tine

test

s co

mpl

eted

by

the

targ

eted

tim

e



Source: Result Turn Around Reports received from lab Includes all sites but excludes Urinalysis and Troponin

Stat Test Turn Around Time

0%

20%

40%

60%

80%

100%


f sta

t tes

ts c

ompl

eted

by

the

targ

eted

tim

e



Urinalysis and Troponin are the only exceptions to the routines and stats

meeting their targets – Urinalysis is not far from the target

Unrinalysis

0%

20%

40%

60%

80%

100%


f sta

t tes

ts c

ompl

eted

by

the

targ

eted

tim

e

Routine Stat Target

Source: Result Turn Around Reports received from lab



Troponin Turn Around Time

0%

20%

40%

60%

80%

100%


f tro

poni

ns c

ompl

eted

by

the

targ

eted

tim

e

Day Shift Evening Shift Night Shift TargetSource: Result Turn Around Reports received from lab

Urinalysis and Troponin are the only exceptions to the routines

and stats meeting their targets –Lab is aware troponin is not

meeting the target and is working on resolution


Ancillary Support – Environmental Services

July 4-July 10, 2004

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Average Rooms Cleaned Average EVS Room Cleaning Staff Total EVS Staff

Clean Beds Vs. Staffing by Time of Day


Ancillary Support – Patient Transport Services

0

5

10

15

20

25

30

Jan Feb Mar Apr May Jun Jul Aug Sept0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Pending Response Volume

Transport Response Time

Transport is reporting incomplete response time starting when the transport is assigned. What are the customer’s

expectations? Volume is relatively flat, why is the pending + response time rising?

Min

uets

Volume


Ancillary Support – Patient Transport Services

The majority of delays are coded as “Nursing”: is this a response to time it takes from request to patient transport? Are there differences in expectations between Transport and Nursing?

Transportation Services DelaysAug. 2004

Doctor Delay12.12%

Nursing Delay53.02%

Unit Patient0.03%

Transportation Delay3.73%

Wrong Info Given1.99%

Equipment Delay6.59%

Patient In Restroom22.52%

Average Mins. Per Delay 12.1Percentage of Jobs with Delay 10.4%Total Delay Hours 171


Ancillary Support

Operational Effectiveness - Timely Deliverable Lab PhysicalTherapy Radiology EVS Transport

Preliminary/Final Report

Evaluation/Treatment

Clean Room

Transport

• Radiology: A report generation system that does not require gaps of time in between steps (in process of implementing a voice recognition system)

• PT: Prioritizing patients and leaving some for the next day• EVS: Bulk of discharges occur when least amount of EVS discharge staff is working• Transport: Huge fluctuations in workload from minute-to-minute

Challenges

Positive current state, needs little improvementNeutral current state, needs some improvement


Ancillary Support – Physical Therapy

Referral Response Time

48

24 24

0

10

20

30

40

50

60

Old Target New Target Actual

Hou

rs


Ancillary Support

Proactive Management System Lab PhysicalTherapy Radiology EVS Transport

Identified/Measured Service Indicators

Target Comparison

Reporting Mechanism

Documented Proactive Approach to Outliers

Diagnosis of Issues Using Objective Data

Resolution Trials

Successful Implementations

• Indicators that are meaningful and that drive day-to-day decision making• Measuring too many or not enough indicators• Challenging or realistic targets • Staff understanding and buy-in to indicators• Believable information (perception versus reality)• Resolution trial that was ineffective – what next?

Challenges

Negative current state, needs much improvement



Ancillary Support

Department Culture Lab PhysicalTherapy Radiology EVS Transport

Morale

Leadership skills and implementation abilities

Staff involved in issue identification and resolution

Staff educated and involved in indicators measured, expectations and results

Department recognizes/responds to internal and external customers needs

Builds good relationships with customer departments

• Balancing quality, service and cost• Never ending demand for faster service• Differing and changing expectations from internal and external customers• Managing time to include issue resolution

Challenges




Ancillary Support – Recommendations

Laboratory• Project capacity of phlebotomist draws based on current staffing and collection times.• Implement special flagging of lab tests for improved response time for patients pending discharge.• Document and trial a “best practice” phlebotomy collection run.• Incorporate order to lab received time by area into measurements and reporting.Radiology• Project capacity for each section based on current staffing and equipment.• It is necessary for IT to support a special flagging of diagnostic procedures in Lab and Radiology for pre-discharged

patients to improve response time for pending discharges.• Analyze no-show, add-ons, cancellations, I/P, O/P, ED, walk-ins and scheduled patients by day for trending.• Evaluate the need to adjust scheduling based on objective data.• Add staff managed measurements relating to quality, service and budget by area.Physical Therapy• Assess use/completion/follow-up of referral trigger within the patient assessment.• Implement discharge notification system in all areas to allow prioritization of patients.Environmental Services• Evaluate roles/responsibilities of staff and time of day for assignments.• Assess staff understanding and compliance of the bed notification and cleaning process.• Implement quality, service, and cost measurement and reporting system. • Define “stat” bed clean and who should be responsible for determining a “stat” status.Transport• Negotiate with external customers on expectations of service – measure and report frequently.• Develop and assign specific downtime duties.• Identify a secure location for equipment storage.

Bed Assignment – Assessment


Turnover /Bed Cycle

Assignment /Patient

Placement


Bed Management

Bed Assignment NursingSupervisors

BedAssignment

Advance bed planning for surgical patients

Considers all possible areas for bed needs

Role in moving patients

Aware of potential discharges

Compare potential discharges with beds needed

Follow up on potential discharges

Effective Bed Management Meeting

Clear prioritization of patients in the bed assignment process

Efficient and coordinated computer systems for bed management

Efficient bed assignment process for specialty beds

• 11 computer screens to be reviewed when placing a patient• Lack of planning/trending of admissions from ED, Direct, Clinics, Cath Lab, other facilities• Required volume vs. available volume of private rooms• Need for one person to be in charge of prioritizing all patient moves (transfers, admissions, discharges)• Lack of accountability system to enforce a streamlined patient throughput process

Challenges




Bed Management

Direct Admit Process Admitting

Easy access for direct admits

Timely registration process for direct admits upon arrival

Timely bed assignment process

Rapid delivery of care

User-friendly direct admit process for doctors and patients

Direct admit process that keeps direct admits out of the ED

• Long waits for bed assignments due to prioritization going to Surgery and ED, and time of discharges• Lack of constant communication and coordination with clinics and patients waiting at home • When a patient waits at home, they will typically go to the bottom of the priority list• Providing care and a comfortable space for patients waiting for a bed assignment• Inability for Physicians to order testing while patient is waiting for bed assignment

Challenges




Bed Assignment Continuous Cycle

Bed assigned Bed assigned at any stage of at any stage of

the processthe process

Reviews multiple Reviews multiple screens of patientsscreens of patients

waiting for bed assignmentswaiting for bed assignmentsReferrals entered Referrals entered

in SMS in SMS

Review multiple screens byReview multiple screens byFloor for bed availabilityFloor for bed availability

Review TeleReview Tele--Tracking for Tracking for further bed assignmentfurther bed assignment

Bed Notification & Identification

Process


University of North Carolina Hospital Planning for Hospital Patient In-Flow

InpatientBed

Outpt.Procedure

ERAdmit

Day Surgery

CathLab

SurgeryAdmit

DirectAdmit

• Gray indicates currently planned volume.

• Red indicates other access areas where the admissions are not being planned for on a daily basis.

Clinic Admit

Trans. from other Hosp.


Bed Assignment – Recommendations

• Define specific role for “Patient Flow Coordinator” to oversee all bed requests. • Redefine roles and responsibilities of bed assignment team.• Implement one large “Bed Board” to visualize all beds in the hospital simultaneously – begin with

a manual magnetic bed board before progressing to a more sophisticated electronic system.• Evaluate need for new technology in Bed Assignment area to allow increased visibility of beds

and eliminate cumbersome bed assignment processes.• Implement “one call” system for physicians to call for direct admission of patients into hospital.• Develop process to plan for bed assignment needs using “Future Scheduled Admissions”

information in SMS.• Develop and implement communication system to gather all necessary information required for

proper bed assignment.• Determine most effective method to determine beds that are out of service.• Define and implement incentive program to identify beds quickly at the front-line staff level.• Pursue opportunities to align supply and demand of beds by service.

Emergency Department – Assessment


Assignment /Patient

Placement



University of North Carolina HospitalMain ED Census and IP Bed Request by Time of Day

June 13, 2004

0

5

1 0

1 5

2 0

2 5

3 0

3 5

0 :0 0 1 :0 0 2 :0 0 3 :0 0 4 :0 0 5 :00 6 :0 0 7 :0 0 8 :0 0 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 6 :0 0 1 7 :0 0 1 8 :0 0 1 9 :0 0 2 0 :0 0 2 1 :0 0 2 2 :0 0 2 3 :0 0

T im e o f D a y

Cen

su

0

1

2

3

Inp

ati

ent

Bed

Req

M ain E D C en s u s A v g # o f IP B ed R eq 's to B ed C trl

C rit ic a l p a t ie n t flo w d e la y p o in ts / P a t ie n t d is s a t is fie r


University of North Carolina HospitalMain ED Transfers by Time of Day

June 2004 Average

0

0.5

1

1.5

2

2.5

3

3.5

4

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

10:0

0

11:0

0

12:0

0

13:0

0

14:0

0

15:0

0

16:0

0

17:0

0

18:0

0

19:0

0

20:0

0

21:0

0

22:0

0

23:0

0

Time of Day

Cen

sus

Admitted Patient ED Transfers

Majority of transfers occur during late evening and night shift


University of North Carolina HospitalED Treat and Release Patient Experience

Actual Patient Chart DataAugust 23, 2004

0:24 0:02 0:27 0:10 3:14

0:00 0:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00

T&R Patient "A"

Check-In to Triage Triage to Reg Time Reg Time to ED Bed ED Bed to Assessment Time Assessment to Discharge Time


University of North Carolina HospitalED Admitted Patient Experience

Actual Patient Chart DataAugust 23, 2004

0:41 2:59 3:54 0:36

0:00 0:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00

Admitted Patient "B"

ED Bed to Assessment Time Assessment Time to Bed Ctrl Request Bed Ctrl Request to Bed Assignment Bed Assignment to ED Transfer


University of North Carolina HospitalCurrent vs. Potential Emergency Department LOS

Current = June 2004 Average

3:00

4:00

1:06

2:36

0:00 0:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00

Treat & Release LOS

Admitted Pt LOS

Target LOS Current Excess LOS

This potential Admit LOS improvement equates to 101 additional hrs of ED capacity per day

This potential T & R LOS improvement equates to 61 additional hrs of ED capacity per day

+

= 162 add'l hrs capacity or 47 add'l pts/day at target blended LOS


Emergency Department – Recommendations

• Develop a strong senior management message around the sense of urgency in improving patient throughput and the role it will play in solidifying the future of UNCH.

• Develop and implement a core set of performance metrics and targets to increase awareness and accountability around the patient throughput process.

• Develop a recognition program that highlights the department/unit specific improvements made in key patient throughput performance metrics on a monthly basis.

• Analyze delay reason details for all ED patient intervals.• Implement an organization-wide “trigger system” with clear action expectations for each patient

throughput process stakeholder during high census days and periods of ED overflow.• Conduct a detailed analysis of ED volume trends and the feasibility of utilizing the Peds ED area

as an alternate care setting to enhance patient flow.

[Portions of the Recommendations are confidential and have been redacted.]


Implementation Plan – Implementation Methodology

ASSESSProject “Blueprint” Development• Outline the strategic implementation plan for the project • Ensure that all initiatives move the organization toward achieving the core set of improvement goals

ANALYZEDetailed Operational Analysis• Focus intensely on operational, financial and performance trends• Initiate the implementation of the Organizational Accountability System• Implement meaningful performance indicators that truly reflect the department’s day-to-day

operations

CONFIRMPerformance Reporting Matrix Design and Implementation• Pilot new initiatives • Install a Performance Reporting Matrix • Monitor outcomes to clarify the impact and provide direction for further implementation • Customize management systems and processes while focusing on leadership development

COMMITFinalize Organizational Accountability System (OAS)• Set performance targets • Finalize performance management tools, performance and leadership metrics• Firm up streamlined, timely reporting processes


• Communicate message to all staff of overall hospital patient throughput philosophy and importance of participation at all levels of the organization.

• Develop project goals and objectives.• Initiate a project structure.

– Patient Throughput Steering Committee– Manager/Director level biweekly update meetings– Front-line staff driven workgroups

• Establish a data tracking system and baseline metrics.– Metrics must be measurable– Metrics must be timely– Metrics must be meaningful– Metrics must be simple

• Determine methods and sources for data collection.• Initiate process change trials and measure success/failure based on established metrics.• Communicate and provide feedback.

Patient Throughput and Capacity Management Next Steps


Implementation

IMPLEMENTATION PLANPHASE I: STRUCTURAL DEVELOPMENTFOCUS AREAS• Case Management• Social Work• Bed Control• Nursing Supervisors

PHASE II: DISCHARGE PROCESS OPTIMIZATIONFOCUS AREAS• I/P Nursing Units• Environmental Services• PACU (limited focus)• Ancillary Services (limited focus)

PHASE III: PATIENT IN-FLOW OPTIMIZATIONFOCUS AREAS• Emergency Department

Weeks 1 - 18

Weeks 9 - 26

Weeks 19 - 36


Patient Throughput Optimization – Implementation Plan – Phase 1

Objectives• Develop and implement an enhanced patient throughput management structure and accountability

system.• Develop and implement a multi-disciplinary Care Coordination model.

Focus Areas• Case Management• Social Work• Bed Assignment• Nursing Supervisors


Implementation Action Plan – Phase ICase Management/Social Work

Phase I Project Weeks

CASE MANAGEMENT/SOCIAL WORK 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

Establish key performance indicators, initial performance targets and reporting process / frequency

Identify performance improvement initiative leaders and focused improvement team members

Set meeting structure for the project for both initiative-level work teams and senior mg progress reports

Identify DRGs targeted for improvement

Assess current care coordination model and discharge planning processes and the impact on patient flow

Study the roles of CM, Physicians, Nursing and Support Services in the LOS management process

Review Communication processes between Case Management staff and Nursing, Medical Staff, Pt/Family, Support Services & Referral Contacts

Analyze clinical practice patterns and cultural issues that impact the ability to optimize LOS

Review clinical pathway utilization

Review opportunities to streamline the clinical documentation process

Analyze managed care denials and related financial impact

Assess appeal and revenue recovery processes associated with managed care denials

Establish and implement care maps for specific "opportunity" DRGs identified within the top 50


Implementation Action Plan – Phase IBed Control/Nursing Supervisors

Phase I Project Weeks

BED CONTROL/NURSING SUPERVISORS 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

Establish key performance indicators, initial performance targets and reporting process / frequency


Implement an interim bed board solution - magnetic board with all beds in service

Develop and implement improvement strategies related to bed assignment process roadblocks by patient type

Track and analyze bed assignment delay reasons by patient type

Pursue opportunities to align supply and demand of beds by service

Develop clear bed assignment guidelines by patient type

Develop and implement an enhanced process that decreases the cycle time from communication of bed needs – room clean – bed assignment – patient transfer/admission

Assist in the selection and implementation process of an electronic bed board application (if necessary)

Senior Management Progress Report



Objectives• Develop and implement an enhanced multi-disciplinary discharge planning and execution

process.

Focus Areas• Inpatient nursing units, including Women and Children’s (39 total units – excluding Psychiatry and

Rehabilitation)• Environmental Services

More Limited Focus• PACU• Ancillary Services – Lab, Radiology, Physical Therapy, Cath Lab


Implementation Action Plan – Phase IIInpatient Nursing (39 Targeted Nursing Units)

Phase II Project Weeks

INPATIENT NURSING 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

Establish key performance indicators, initial performance targets and reporting process/frequency


Set meeting structure for the project for both initiative-level work teams and senior mgt progress reports

Analyze unit-specific patient mix and develop appropriate patient flow expectations and performance indicators

Develop and implement unit-specific tools to track key patient flow and discharge indicators

Develop and implement a daily day before discharge planning and communication process

Establish and implement a formalized discharge process and targeted discharge time

Establish a process to identify and communicate discharge needs upon admission

Implement a daily review process for pending discharges, and required action

Implement a special flagging of lab tests, diagnostic proceduresand other ancillary services for improved response time

Define and implement an incentive program to identify beds quickly at the front-line staff level

Evaluate the following options for enhancing patient flow: extended stay recovery area, Observation Unit, Clinical DecisionUnit, Discharge Lounge


Implementation Action Plan – Phase IIAncillary Services

Phase II Project Weeks

ANCILLARY SERVICES 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

Establish key performance indicators, initial performance targets and reporting process/frequency


Set meeting structure for the project for both initiative-level work teams and senior management progress reports

Evaluate roles, responsibilities of staff and assignment methodology by shift

Assess staff knowledge and compliance of their role in patient throughput

Align staffing levels and work load by time of day to support optimal patient flow




Objectives• Decrease the I/P delays from the ED.• Optimize the patient throughput experience within the ED.

Focus Areas• Emergency Department


Implementation Action Plan – Phase IIIEmergency Department

Phase III Project Weeks

EMERGENCY DEPARTMENT 19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

Establish key performance indicators, initial performance targets and reporting process/ frequency


Set meeting structure for the project for both initiative-level work teams and senior mgt progress reports

Prioritize and implement improvement strategies for delay reasons for "patient in-room – disposition: patient flow

Prioritize and implement improvement strategies for delay reasons for "disposition - bed assignment“ patient flow interval

Prioritize and implement improvement strategies for delay reasons for "bed assignment - transfer" patient flow interval

Develop and implement clear expectations and indicators for timely Nursing - ED communication on IP transfers

Analyze current ED treatment philosophy and its impact on patient flow (compare to best practice)

Perform a feasibility study on utilizing the Peds ED area as an alternative care area to enhance patient flow



Financial Impact

Opportunity Description Operational Impact Financial Impact Comments

Direct Financial Benefit and Impact on ROI

Decrease excessive days

Decrease excessive days by 12,000 to

14,500$4.2 M to $5.1M

Projected opportunity represents impacting total excessive days by 50% to 60% at a savings of $350 per day.

Back-fill opportunity

Additional capacity for 1,300 to 1.600 potential additional discharges

$5.5M to $6.6M

Opportunity calculation based on an estimated contribution margin/case of $4,123 per an analysis completed by Decision Support. Feasibility of back-fill opportunity will be analyzed during the implementation phase.

ED Length of Stay Reduction

Decrease in elopement rate

1 to 2 additional treat and release patients

per day$550,000

Projected opportunity represents decreasing the elopement rate from 3.8% to 2.0%, which equates to an increase in ED charges based on the average charge per visit of $914.

Indirect Financial BenefitImprove Observation I/P Conversion Process

Converting patients from Observation status to I/P when appropriate will improve revenue opportunity.

These financial benefits will be realized as a result of the Care Management initiatives of the Patient Throughput and Capacity Optimization Implementation Plan.

Decreased Variable Costs – Improved Productivity

Increased throughput without a change in staffing levels will decrease valuable costs per unit of service and increase productivity.

Accountability systems and performance metrics implemented during the engagement teach the front-line managers how to proactively manage volume and plan for daily workload.

TBD DURING IMPLEMENTATION

PHASE

Length of Stay Reduction


Key Components for Success

• Recognize that patient throughput is a hospital-wide issue, not just an issue for particular departments, such as the Emergency Department and Surgical Service.

• Develop and communicate an overall hospital patient throughput philosophy.

• Communicate a message to all patient care givers that everyone is accountable for patient throughput.

• Establish and communicate clear, measurable indicators and outcomes.

• Measure the process on a continuous basis.

• Design and manage patient throughput as a single seamless beginning to end process.

section xiii capacity management / throughput

Documents