Patient Bill is spending his 18th hour in the ED, waiting for an inpa-tient bed. Between the gurney and the kidney stones, he feels misera-ble. Patient Jane’s surgeons performed an excellent hip arthroscopy - but her healing is at risk because the only space for physical therapy is in the PACU. If she could get up to the floor, she’d recover faster.

Discharge before Noon (DBN) improves flow in our hospital and helps patients heal

1. On our highest census days, we’ve had >20 ED boarders and >10 PACU boarders at midnight.

2. ED studies link ED Length of Stay (LOS) > 5 hours and Boarding > 6 hours to poor CVA/ICH out-comes and higher (+4.5%) in-hospital mortality (for critical care patients)1.

3. Over the last year of improved DBN, we’ve seen Patient Satisfaction with Discharge2, Length of Stay (LOS)3, and Readmissions4, remain level, indicating that we can level discharges without sacrificing out-comes.

%Pts DBN in Hospital Medicine

Discharge before Noon requires a change in daily habits, and in the fol-lowing pages, we’ll explore how you and your team can improve flow, and thus better your patients’ lives.

1: Berstein et al. SAEM, 2008. Rincon et al. Neurocrit Care, 2010. Chalfin et al. Crit Care Med, 2007 2: DC questions, 84.9 average +/- 1.6% 3: LOS Index 1.11 average, range 1.08-1.17 4: all cause 11.49% average +/- 0.76%

Stories to Spread

I N S I D E T H I S I S S U E :

Cover & News 1

Discharge before Noon

2-3

Enterprise Analytics Spotlight

4

CPI Announcements

U C S F H E A L T H

Transformations M A R 2 0 1 5 V O L U M E 1 , I S S U E 2

Discharge by Noon 20% = 18 patients total

1 patient /team /day “Who’s going home in the

morning?”

C P I N E W S -L E T T E R It takes courage and inspiration to

change the status quo.

Our CPI Website has launched at cpi.ucsf.edu. Visit it to learn more about CPI and meet our Partners. You’ll also find our Data Portal, the place where anyone at UCSF can go to request data.

We held our second UBLT workshop on 3/12 focused on Change Management. You can find pictures and the ppt on our website. Cynthia Chiarappa provided an inspiring presentation on the power of Lean Healthcare.

CPI 101 is in full development. This 5-module introductory course aspires to provide everyone the basics in CPI, Lean, and the domains of Quality, Safety, Experience, and Finance. Our goal is to release the first on these in Quarter 1 of FY 2016.

Michael Wang

Data Specialist

The man behind the Data Portal

T H E C P I F O R E C A S T A P R

Second wave of UBLTs chosen

J U N

Results from first UBLT Improve-ment cycle

J U L - S E P

CPI 101

Second wave of

UBLTs kicks-off

E D I T O R Todd Elkin

Want to share a great story of CPI? Email cpi@ucsf.edu. Find our website at cpi.ucsf.edu

P A G E 2

“A safe and

effective discharge

starts the moment

the patient is

admitted,”

Adrienne Green,

Associate CMO

Example: Discharge Process Map [14M/L]

First: Name the Patient

Going to Gemba In Search of DBN Going to Gemba is the Lean approach of going to where the work is done, to truly understand the problem.

We interviewed 14M/L and 8L/S, two teams who have invested heavily into DBN.

They started with a question:

“What is OUR discharge process?”

They discovered no single person knew it start-finish, so they mapped the process. See an example below.

How do you start?

Here are two successful ap-proaches [#1:8L/S, #2:14M/L]

1) Host a 2 hour meeting with all roles who touch the patient. Use sticky notes for each activ-ity or process related to dis-charge, then arrange them in a flow. This “map” is critical.

2) Appoint a Physician Champi-on (attending or fellow) to study the process for a month. Interview key roles and docu-ment the needs of each to get a patient discharged.

Remind yourself that…

… every team is different. The importance of Going to Gemba is to learn what your team needs.

… we shouldn’t work harder. Your goal is to level the dis-charges (not increase them). So that patients leave through-out the day, not only in the afternoon.

Below are some process opti-mizations that have helped other units.

Understand The Barriers

Fear of being wrong. Caregiv-ers hesitate to make predic-tions until they are certain.

Risk Aversion. There’s a ten-dency to want to wait, to re-duce the risk of re-work.

With all the steps in the dis-charge process, we can’t wait.

“John is going home in the morning.”

Simply naming the patient is the most effective way to in-crease discharges before noon.

It’s simple, but not easy.

What you can do

Model and Teach that it’s ok to be incorrect. If a test comes back and the patient needs to stay, that’s fine.

Ask caregivers to queue up the work by doing as much in ad-vance as they can.

This visual, color-coded by role, helps the team see the col-laboration and com-munication needed to discharge a patient.

It’s the first step in figuring out where to focus your efforts.

T R A N S F O R M A T I O N S

Mary Reid, Nurse Manager for 8L/S,

exploring the discharge process with her team

Discharges

Admits

By moving our median discharge time earlier,

we improve patient flow

Second: Optimize the Day Before P A G E 3 V O L U M E 1 , I S S U E 2

It takes two hours to perform all of the discharge tasks. Thus the Dis-charge Order needs to be written by 10AM.

This means the day before is vital.

Tee Time Rounds: In the after-noon, ask “What’s left to be done?” and tee-that-up so the patient can be discharged in the morning.

Set expectations with patient & family

Round on previously identified DBN patients before other stable patients

Tee Time can vary by unit...

14M/L does it at 230pm, with at-tendings and residents talking with the case managers. Ideally, it’s all three in person, but can work with one physician, and via phone.

8L/S does it at 5pm, with the case manager initiating an email of out-standing tasks to the resident, charge nurse, pharmacist, and nurse manager.

Find the best time and forum for your people to review the next day’s discharge needs.

Multidisciplinary Rounds (MDR): This rounding happens every morning, with the full care team when possible, led by the case managers.

The focus is to confirm which pa-tients are ready to be discharged today, and to prioritize any pa-tients who could leave by noon.

In July 2013, we were at 16.6% DBN across all UCSF. Because of your attention, we’re now averag-ing 20.5% since April 2014 (graph above), even with a dip in February.

Success at Discharge Before Noon is something that takes consistency and focus, every single day.

When asked about DBN, Katie Raffel, PGY2, reflected: “Each transi-tion-- from the ED to the unit, from the hospital to the location where you'll continue your recovery-- is a step closer to feeling better, feeling like you again. DBN assures that these transi-tions are timely... and safe.”

Let’s keep up the great work! The more we can balance our dis-charges across the day, the better our hospital will flow, and the healthier and happier our patients will be.

whereas in 8L/S those physicians are doing surgeries in the OR. Thus, though the goal was the same, 14M/L chose an in-person, in-real-time, model, while 8L/S chose a virtual, asynchronous, model. Otolaryngology discovered that they needed to complete all floor work before they went to the OR each day. For the most complex patients, they start working with

Case Management days before anticipated discharge. The Takeaway:

1. Understand how your team communicates, and optimize that process.

2. Keep asking: “how can WE get one patient discharged before noon every day?”

Every unit and area is different, and while some solutions can be standardized, it’s important to rec-ognize which ones need customiza-tion. For example, consider 14M/L and 8L/S. They both implemented effec-tive Tee Time Rounding processes, but the details look quite different. 14M/L has attendings and residents that are available during the day,

Knowing YOUR Unit

Celebrating

“The Otolaryngology

service has been

successful at discharging

patients early by getting

the prep work

completed the day

before,” says Matt

Russell, OHNS Surgeon

Want to share a great story of CPI? Email cpi@ucsf.edu. Find our website at cpi.ucsf.edu

CPI Partner Spotlight

We Can Help You We empower decisions makers with analytics that advance UCSF’s ability to care, heal, teach and discover. We do this by working with our business and clinical customers to enhance the value of UCSF’s data assets by organizing, integrating and governing them. Then we help develop targeted analyses that provide important insights, such as:

§ How successful are we at engaging patients and where can we improve?

§ How can a study be designed so that there is a large enough cohort of patients to meet study objectives?

§ What are our volumes, revenues and collections, and how do they compare to this year’s budget and prior years?

§ Which students need additional assistance to be successful and how is this correlated with their prior experiences?

§ How is our clinical quality trending over time and where are improvements needed?

§ Which patients are at risk for sepsis and how effective are our sepsis bundles?

Our Team Our staff specialize in clinical informatics, data governance, business intel-ligence, dashboard development, and data architecture and management. We offer two types of packaged services: a full lifecycle set of services where our core team develops analytic work products for our custom-ers, and; a franchise model where the customer takes responsibility for developing their own analytics with our core team providing assistance in data governance, technical architecture, and training and access to BI technologies.

Our core team and customer franchises have developed the dashboards found at http://datacatalog.ucsfmedicalcenter.org, also on the Carelinks page under the Dashboard – Data Catalog & Analytics link. In addition, we have developed a data catalogue that lists all 750+ metrics that are available on the dashboards, their definitions, data sources, calculations and business owner. To gain access to dashboards submit an Account Request Form, http://arf/, with your direct supervisor’s approval.

P A G E 4

We look forward to partnering with CPI, UBLT teams and our other customers to help them address their most vital and pressing prob-lems. While our offices are located at MCB, we’re happy to come collaborate with you and your team. Please feel free to contact the Enterprise Analytics Team at EnterpriseAnalytics@ucsf.edu with any questions, concerns and / or request for data, dashboards or other types of analytics.

UCSF Enterprise Analytics

Team Mission:

Advancing UCSF’s ability to care, heal, teach

and discover through accurate and actionable

analytics.