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SQUEEZING WATER FROM A STONE: MAXIMIZE YOUR EXISTING RESOURCES AND ENHANCE YOUR PATIENT FLOW PROGRAM
2011 Becker’s Hospital Review Annual Meeting
May 19-20, 2011
Lisa Romano RN, MSN
Much of the coverage of the health care reform law in its early
stages has focused on efforts to expand health insurance
coverage. But the law has another focus as well ….. improving
the quality and value of medical care.
Healthcare Reform
April 29, 2011 Don Berwick – Administrator, Centers for Medicare & Medicaid Services
The Department of Heath and Human Services (HHS) announced on April 29, 2011 the Hospital Value-Based Purchasing Program, created under the Affordable Care Act.
This program provides hospitals with incentive payments
based on their performance on health care quality measures such as:
How quickly do heart attack patients receive interventional
procedures? How often do patients with heart failure get the discharge
instructions they need to help them care for themselves? How satisfied are patients with their experience of care at the
hospital?
Hospital Value-Based Purchasing Program
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Effective as of 2012
•Physician payment reforms are implemented in Medicare to enhance
primary care services and encourage doctors to form "accountable
care organizations" to improve quality and efficiency of care.
•An accountable care organization (ACO) is a type of payment
and delivery reform model that starts to tie provider
reimbursements to quality metrics and reductions in the total cost
of care for an assigned population of patients. A group of
coordinated health care providers form an ACO, which then
provides care to a group of patients.
•An incentive program is established in Medicare for acute care
hospitals to improve quality outcomes.
Healthcare.gov
What can we expect from Healthcare Reform?
•The Centers for Medicare and Medicaid Services begin
tracking hospital readmission rates and puts in place
financial incentives to reduce preventable readmissions.
Effective as of 2013
A national pilot program is established for Medicare on
payment bundling to encourage doctors, hospitals and
other care providers to better coordinate patient care.
What can we expect from Healthcare Reform?
Healthcare.gov
How can an efficient patient flow program help?
Goals
•Ensure timely access to healthcare for all
•Improve the quality of care
•Ensure safe patient outcomes
•Reduce Hospital Acquired Infections (HAI)
•Prevent readmissions
Strategies for Goal Achievement
Obtain immediate notification of patient discharge
Decrease bed turnover times
Decrease patient wait-times
Assign the right patient into the right bed the first time preventing lateral moves
Ensure timely transfer of ready patients into ready beds
Track patient movement throughout the course of stay
Notify physicians real-time that lab/test results are ready
Track equipment for efficient retrieval for use during patient transport and loss prevention
Immediately locate biomedical equipment so that ordered IV intervention or monitoring is not delayed
Reduce exposure to pathogens Contact with Healthcare personnel Biomed Equipment is clean (pumps, monitors) Transport devices are clean (wheelchairs, litters)
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Characteristics of an organization not practicing Precision Placement – a Rocky Road
•Multiple phone calls
•Rounds to look for beds
•Multiple bed meetings
•Delayed discharge notification
•Delayed room cleaning
•Long waits for transport
•Placement of “not-ready patients” into “Ready Beds”
•Off-service placements with lateral transfer to right-service bed during inpatient stay
•Extreme examples of Symptoms of Overcrowding (as noted previously)
Avanti Patient Flow Services 2010 8
Symptoms of a System-Wide Capacity Issue
Delayed/canceled OR procedures Extended ED wait-times ED Hallway Patients ED LWBS (left without being seen) Ambulance Diversion/silent diversions Placement of Patients off-service Delayed Discharge Notification Long bed turnover times
1.
Delayed discharges on med/surg units
increases bed occupancy
2.
Med/surg floors are full;
CCUs/intermediate care units
become backed up
with patients that can’t be
moved to med/surg units
3.
Hospital operates at
critical census; ED and PACU
becomes full with patients unable
to move to any unit
4.
New patients cannot be
admitted; ED forced to
go on divert;
transfers denied and
OR cases canceled
Stages of Throughput Gridlock
GRIDLOCK
9
Avanti Patient Flow
Services 2011
4
Past: Manual World
Past: Manual World
Do I have a bed on
Mr. Smith?
No
2nd call: Do I have a bed on
Mr. Smith?
No
3rd call:
Do I have a bed on
Mr. Smith
When will it be
ready?
Bed Meetings, Multiple telephone calls, “rounds” to look for beds – A
fragmented process wrought with delays and frustration
5
Characteristics of an organization practicing Precision Placement - A Smooth Path
•Minimal phone calls
•Rounds are clinically focused on expediting the transfer of assigned patients into ready beds
•No bed meetings
•Immediate discharge notification
•Housekeeper is dispatched immediately upon discharge notification
•Timely room turnover
•Efficient/timely transport of patients
•Placement of “ready patients” into “Ready Beds”
•Minimal off-service placement
Avanti Patient Flow Services 2011
6
Precision Placement Opportunities
Elective Schedule Specialty Service and/or Procedure Placement(s)
Elective Surgery Cases assigned based on scheduled incision time – use of confirmed discharge bed for later cases
Inpatients going to OR and not returning to beds – beds are released and assigned in am to new patients
ED cases going to OR before they are transferred to assigned inpatient bed are not assigned a bed prior to leaving the ED
Cath Lab Cases that inpatient bed decision is dependent on results of diagnostic cath are not assigned a bed until decision is made – go to a post-procedure area
Orthopedic
Cardiac
Neurology
Neurosurgery
Peritoneal Dialysis
Chemotherapy
Traction/joint devices
Negative Airflow
Lead-lined Rooms
Bariatric Surgery/Rooms
Avanti Patient Flow Services 2011
Discharge Planning Milestones
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Bed Assignment Priority Indicators
BPIs are easily assigned on the Portal list views.
BPIs are displayed on the bedboard for Patient Placement. BPIs can also be assigned from bedboard.
PatientTracking Portal XT
(Nursing Unit View)
The electronic bedboard
(Patient Placement View)
Portal XT: Inpatient Units and Source Admission Areas (PACU, A & E, Cath Lab) can stop
calling for Bed Assignment/Status Information – Bed control uses BedAhead Priority Indicators to make assignments
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Time for placement strategy. Unnecessary phone calls are eliminated.
Nursing units use portal and the bedboard to
communicate and receive their real-time bed information.
Charge Nurses enter
BedAhead Priority
Indicators
Centralized Bed Control assigns bed
using BedAhead
Admission Source areas
refer to BedBoard & Portalfor bed assignment
Status of Bed is
updated real-time on BedBoard &
Portal
Beds upgraded by Bed Control
to Clean Next or Stat as indicated
Patient is moved when bed is clean
Avanti Patient Flow
Services 2011
Instant Notify used to inform destination of critical update
• Uses Bed Ahead
• Upgrades to a clean next or stat if necessary
Patient Placement assigns a bed in the order preferred by nursing,
ensures prompt room turnover ,and notifies destination area of ETA
and clinical condition in under a minute
Patient Logistics Implementation: Key Elements
Timely notification of patient discharges (Transport Tracking Implementation)
Timely turnaround of “discharge” beds (BedTracking Implementation)
Timely assignment of “ready” beds (PreAdmit/Electronic bedboard Implementation)
Timely movement of patients to ready beds (“Pull” system)
Avanti Patient Flow Services 2011
9
Central Patient Transport
Central Patient Transport assumes responsibility for all discharge escort
Discharges are assigned a high-priority in system
Reporting structure changed to patient logistics
Transport Tracking Software used
Real-time interface with BedTracking and PreAdmit Tracking results in: immediate notification that discharge has occurred
Immediate dispatch of cleaning job to housekeeping
Avanti Patient Flow Services 2010
DBST - Discharge Bed Swat Team
Team of dedicated housekeepers
Devoted to cleaning of discharge and transfer beds only
Staggered shifts based on dirty bed hourly distribution
Dispatched to clean dirty bed via BedTracking
Uses alpha pager and bedside phone to communicate updates
No competing priorities
Avanti Patient Flow Services 2010
Automation with Precision Placement
founded on Best Practice Patient Flow
Strategies yields Incredible Results
10
Case Study #1
1000 bed Level 1 trauma and burn center across three campuses.
Problem Statement:
Overcrowding and lost business from ED LWBS and Transfer Center denials due to bed availability.
Solution:
Implementation of TeleTracking CMS along with centralization of patient placement and transfer center for multiple campuses
Results (scorecard) Transfer Center admission growth 20% admission growth over 3 year period– all campuses – all patient types Dramatic Reduction in Operating Theatre Hold Reduction in A & E wait times Bed Turns at top quartile (advisory board measure) Improved A & E patient satisfaction
Transfer Center Aborts due to Bed Availability
Jan 2003 - Jan 2006
0%
2%
4%
6%
8%
10%
12%
14%
16%
Jan-
03
Mar
-03
May
-03
Jul-0
3
Sep-0
3
Nov
-03
Jan-
04
Mar
-04
May
-04
Jul-0
4
Sep-0
4
Nov
-04
Jan-
05
Mar
-05
May
-05
Jul-0
5
Sep-0
5
Nov
-05
Jan-
06
Month
Bed
Ab
ort
s
020406080100120140160180200220240260280300320340360380400420440
# o
f T
ran
sfe
r C
en
ter
Req
uests
% Bed AbortsTotal Trans. ReqTotal Trans Req Trend% Bed Aborts Trend
Requests continue to rise while bed availability refusals decline as
A more efficient bed search process across 3-campus system allows
Transfer center coordinator to confirm acceptance within 10 minutes of call
Dramatic Reduction in OR HOLD
LVH-CC OR Long Holds Monthly Avg by Year
0
150
300
450
600
750
900
1,050
1,200
2003 2004 2005 2006 2007
Year
Av
g M
inu
tes
on
Ho
ld p
er
Mo
nth
0
5
10
15
20
25
30
35
40
Av
g #
Ca
se
s o
n H
old
pe
r
Mo
nth
Minutes OR on Hold
Cases on Hold
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2003 2004 2005 2006 2007
% LWBS 2.8% 1.9% 2.1% 2.0% 1.6%
ED Visits 49,187 49,896 53,288 56,099 59,448
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
# o
f E
D V
isit
s
% o
f P
ati
en
ts L
WB
S
Calendar Year
ED Patients Left Without Being Seen (LWBS)
% LWBS ED Visits
Left Without Being Seen in Emergency Department ( A & E)
ED Patient Satisfaction CC-ED
percentile rankings
30
9585
7077
0
20
40
60
80
100
2003 2004 2005 2006 2007
Fiscal Year
Pre
ss G
an
ey P
erc
en
tile
Patient logistics/ Teletracking implemented
Patient Satisfaction
3.8%
0.7%
1.7%1.4%
6.2%
5.3%
8.4%
2.0%
-2.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
55,000
1998 1999 2000 2001 2002 2003 2004 2005 2006
Gro
wth
Ra
te
Fiscal Year
Acute AdmissionsNetwork Admissions
Growth Rate
Acu
te In
pati
en
t A
dm
issio
ns
BedBoard implemented20% admission growth over next 3 years
Bed turns began at 48 and increased to 62
12
Meeting Industry Standard: Do we meet the Advisory Board’s Expectations?
Sample hospital with Centralized Bed Control and Best
Practice Use of Patient Placement Technology
* Benchmark source: Advisory Board “True North
Publication
78 79 78 78 78 78
0
10
20
30
40
50
60
70
80
90
100
Jan Feb Mar April May June
BedTurns (staffed beds divided by # of admissions annually)
average annual bed turns top quartile 61*
BedTurns (staffed beds divided by # of admissions annually)
Case Study #2
Premier medical facility with > 1800 beds and an impressive array of specialty services
Problem Statement:
Overcrowding and lost business from ED LWBS and Transfer Center denials due to bed availability.
Solution:
Implementation of TeleTracking CMS along with centralization of patient placement and Transfer Center across multiple campuses
Results (scorecard) Impressive Transfer Center admission growth Reduction in time from bed request to assignment Reduction in A & E wait time
13
336
299
189 170
152 153
191
115
194
146
98
0
50
100
150
200
250
300
350
400
Jan Feb Mar April May June July August Sept Oct Nov
# pts
2009 58,000 visit ED – No Diversion Policy
LWBS (Left Without Being Seen)
Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 March '10
341 424 446 466 469
639
Total Transfers (Oct '09-March '10)
(3%)
(97%)
(96%) (96%)
(98%)
Total Transfers: 352
Total Transfers: 441
Total Transfers: 464
Total Transfers: 477
25% Growth from Oct
5.2% Growth from Nov
3.0% Growth from Dec
(98%)
Total Transfers: 479
1% Growth from Jan
34.0% Growth from Feb
Total Transfers: 644
(99%)
14
Best Practices to maximize use of Patient Flow technology
Entry of pending discharge
Update pending to confirmed with use of precision placement
Transport escort of discharges with interface to bedboard
Transport discharge escort interface to housekeeping to clean the bed
Dedicated cleaning team for discharge and transfer beds
Use projected census to better align resources with demand
Centralized Bed Control with use of BedAhead to assign beds
Use of Discharge Planning Milestones to facilitate early discharge and precision placement
Transparency of information
Implementation of a “Pull System”
Data driven patient flow program with goals for all patient flow stakeholders incorporated into performance evaluation
15
Bed Alert: M/S near full-capacity LLM/High-level at
full-capacity – 20 post-ops, 7 ED holds, projected census
to hit 99% within 3 hours
“Pull Systems” ensure Timely Movement of Ready Patients to Clean & Ready Beds
Rapid, Streamlined communication between feeder areas and patient units Capacity Management Software
Avoid “phone tag” – unnecessary phone calls
Hold staff accountable to timely transfer/patient acceptance
Create a Pull System
Provide Community Command Center with Real-time Bed Capacity Information
The powerful impact of Remote Locationing Systems (RTLS) on patient flow
Integration of RTLS into the Capacity management Suite (patient flow software) allows for immediate decisions based on real-time patient movement information.
This becomes the foundation of Precision Placement.
Immediate discharge notification Immediate page to housekeeping
to turnover bed when discharge occurs
Immediate notification that transfer of patient has occurred (or didn’t occur) into assigned bed
Continuous updates on location of hallway/overflow patients
Ability to immediately locate necessary equipment
16
100% bed-level accuracy
Timely, robust data
Network-friendly
Easy installation
Power-efficient
Low Total Cost of Ownership
About Teletracking RTLS
A Real-Time Location System (RTLS) that uses a combination of reverse IR and traditional RF (estimated) technologies to track people and assets.
Track at zone, room, or bed level
Full coverage (bed) •Staff Locating / Nurse Call •Hand Washing Compliance
•Asset Management •Patient Tracking •Workflow
No Hallways (room) •Asset Management •Patient Tracking •Workflow
Choke Points (zonal) •Asset Tracking
Hallway only (zonal) • Asset Tracking
= Beacon
= Virtual Walls
= Eth. Collector
= Wi-Fi Collector
Lisa Romano RN, MSN Sr Vice-President & Chief Nursing Officer,
TeleTracking Technologies, Inc.
(610) 504 -3078 [email protected]
Questions?
