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11/27/2013
1
C4: The Improvement Opportunity in
Real-time Location Systems
Dennis S. O’Leary, MD Marilyn P. Chow, RN, PhD, FAAN
1
Presenter Disclosures
• Dennis S. O’Leary, MDo President Emeritus of The Joint Commission
o Chief Medical Officer, Awarepoint Corporation
• Awarepoint is one of a number of RTLS companies
• Marilyn P. Chow, RN, PhD, FAANo Vice President, National Patient Care Services, Kaiser Permanente
• No conflicts to disclose
2
11/27/2013
2
Learning Objectives
• Explain the basic design of a Real-time Location System (RTLS).
• Describe three RTLS applications that address patient safety issues.
• Provide two examples of data-based improvement opportunities in the typical Emergency Department.
• Describe two ways in which RTLS supports significant cost reductions.
3
Primary Goals for Healthcare Technology Solutions
• Quality Healthcare Deliveryo “Delivering compassionate, high quality, affordable healthcare
services.”
• Cost Managemento “Creating efficiencies, reducing costs, and streamlining clinical
and business processes.”
• Risk Mitigationo “Mitigating financial, operational, and clinical risks.”
• Process Improvemento “Identifying utilization and performance improvement
opportunities throughout an organization.”
4
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The Battle to Improve Patient Safety: Are We Winning?
• Significant preventable adverse events occur in one in every 7-10 hospitalized patients.
• Over 2 million healthcare-acquired infections are identified each year.
• Medication errors harm at least 1.5 million people (400,000 in hospitals) every year.
• Level of harm incidents (25 per 100 admissions) unchanged over 6 years.
5
Top Hospital CEO Concerns
2010 2011 2012
Financial challenges 1 1 1
Patient safety and quality 4 3 2
Healthcare reform implementation 2 2 3
Government mandates 3 3 4
Care for the uninsured 6 5 5
Patient satisfaction 7 7 6
Physician-hospital relations 5 6 7
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The Multiple Faces of Waste… and Safety Exposures
• Steps in a process that add no value
• User-unfriendly hospital design
• Illegible prescriptions
• Avoidable patient re-admissions
• Decubitus ulcers, patient falls
• Management of common conditions, e.g., low back pain, depression
7
Problems andImprovement Opportunities
• Quality of Careo Wasted nurse time looking for equipment, constrained direct patient care
time, long order to care delivery time, patient and staff satisfaction issues
• Cost Managemento Suboptimal asset utilization; lost, stolen, misplaced equipment; capital
budget redundancies; excessive rentals
• Risk Exposureo Ineffective equipment recall and PM management processes; reduced
temperature monitoring compliance; preventable hospital acquired infections
• Missed Opportunitieso Ambulance diversions / ED patients LWOT, OR case delays, slow bed
turnover
8
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Real-time Location Systems (RTLS) Defined
• Wireless technology that permits the tracking of moveable medical equipment, patients, and staff inside hospitals
• Include applications for monitoring and managing care workflow in discrete locations (e.g. OR, ED), for temperature monitoring, and for monitoring hand hygiene
• Have enterprise-wide coverage capacity of over 4 million square feet
• Produce data-based outcomes that empower evidence-based decision making
9
RTLS Data Flow
10
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RTLS Technologies (Active)
• Radio Frequencyo WiFi
o ZigBee
• Ultrasound
• Infrared
11
5 Critical Success Factors
1. Enterprise-Wide Coverageo Assets and people move throughout the organization. Optimal
improvement requires complete overview of location, status and movement
2. Room Level Accuracyo Crucial to enable long-term clinical and financial outcomes
3. Non-Disruptive Installation and Low Ongoing Maintenanceo Minimal operational disruption, systems’ interference, and IT burden
4. Standards-Based Interoperabilityo Allows 3rd party integration; scalable solution supports current and future
needs
5. Proven, Flexible, Low Risko Referenceable ROIs, flexible business model
12
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WiFi Channel Utilization
13
2400
MHz
2483.5
MHzIEEE 802.11b (WiFi)
Channel 1 6 11
2412 2437 2462
WiFi Deployment Optimized for Data Throughput
14
1 6 11
1 6 11
1 6 11
6 11 1 6
1 6 11 1 6 11
Good Channel Utilization
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8
WiFi Deployment - Accuracy vs. Bandwidth Tradeoff
15
1
6
6
11
1
6
11
1
6
1
6
11
1
11
6
1
11
6
1
6
11
1
6
Best Channel UtilizationWorst Channel Utilization
Worst Location AccuracyBest Location Accuracy
WiFi Pros and Cons
Pros Cons
16
• Everyone has a WiFi network
• Provides accuracy within 3-9 meters (10-30 feet)
• Perceived as an easy entry- point for RTLS
• Not enterprise wide
• Not room-level accurate
• Difficult to install and maintain
• Consumes bandwidth on mission-critical network
• Requires additional technology (ultrasound, infrared, etc.) to drive clinical workflow
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9
ZigBee Channel Utilization
17
2400
MHz
2405 2410 2415 2420 2425 2430 2435 2440 2445 2450 2455 2460 2465 2470 2475 2480 2483.5
MHz
IEEE 802.15.4 (ZigBee)
Channel 11 12 13 14 15 16 20191817 21 22 26252423
2400
MHz
2483.5
MHzIEEE 802.11b (WiFi)
Channel 1 6 11
2412 2437 2462
ZigBee Wireless Sensor Network (WSN) – Room-Level Accuracy
18
Flexible Deployment, Self-Forming Multipoint Calculation
Continuous Calibration, Self-Healing
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10
ZigBee Pros and Cons
Pros Cons
19
• Enterprise Wide
• Room- and bay-level accurate
• Easy to install
• Easy to maintain: auto-calibrates, self-heals
• Redundant
• Doesn’t interfere with mission-critical WiFi network
• IT-centric buyers want to use WiFi (don’t understand challenges with accuracy, etc.)
• Represents a second wireless network
Infrared Technology
An LED transmits infrared signals as bursts of non-visible light; a photoreceptor detects the light pulses
20
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11
Infrared Pros and Cons
Pros Cons
21
• Good room-level accuracy
• Complements WiFi strategy
• Poor enterprise-wide coverage
• Some technology requires hard-wiring
• Difficult to “tune” for accuracy
• Tag failure rate is high (mechanical, battery life)
• Can be “shielded” by blankets, clothing, etc.
Ultrasound Strategies
An oscillating sound pressure wave with a frequency greater than the upper limit of the human hearing range
22
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12
Ultrasound Pros and Cons
Pros Cons
23
• Good room-level accuracy
• Complements WiFi strategy
• Poor enterprise-wide coverage
• Difficult to “tune” for accuracy (though less difficult than Infrared)o Strategic hardware placement
helps
• Can have “shielding” issues
Asset Management: Key Financial and Clinical Outcomes
Tracking
• Improve Staff Productivity | Minimize Risk (Recalls, PMs, Sterile Process)
Rentals
• Control expenditures
Utilization
• Optimize inventory levels
Shrinkage
• Reduce lost, misplaced, stolen
Temperature Monitoring
• Actively monitor | Reduce loss or misuse of temperature sensitive asset
24
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13
25
Kaiser Permanente• 7 regions serving 8 states and the District of Columbia
• 9.1 million members
• 16,000 physicians; 174,000 employees (including 48,000+ nurses)
• 38 hospitals
• More than 600 medical offices (ambulatory care buildings)
• $50.6 billion operating revenue (2012)
26
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14
Current RFID Use Cases Installed
27
Active RFID Tag Adoption at KP
Production
Total Asset Tags ~147,000
Temperature Sensors: ~6,500
Wireless Location Coverage: ~32,000,000 Sq Ft
Active RFID (RTLS)• Asset Tracking• Equipment Maintenance• Asset Management• Rentals• Equipment Loss/Shrinkage• Temperature Monitoring• Infant Safety
Passive• Retained
Foreign Objects
Active RFID Geographical Activity
0
25,000
50,000
75,000
100,000
125,000
150,000
2009 2010 2011 2012 2013 2014
Implementing
Historical Timeline Kaiser Permanente has a long history with RFID, which has recently become a prevalent infrastructure
RFID Data Collection
RWJF Time and Motion study,Marilyn Chow and
Ann Hendrich
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Asset Tracking Pilot
LA Medical Center
RWJF Time and Motion study,
Marilyn Chow and Ann Hendrich
Journal Article
Asset Tracking
5+ Sites
Tracking & Temp
Hawaii
Garfield RTLS Purchase
Asset Tracking,
Temperature
18 Sites
Tracking &
Temp
Mid-
Atlantic
Purchase
SmartCareIntro
Time & Motion
S. Sacramento, Roseville
Tracking &
Temp
NCAL Triplets
Passive -
OR Sponges
Care-FusionIV Pump Purchase
Labor Mgmt Collaboration
Active RTLS introduced to healthcare roughly around early 2000.
NCALSCAL
1st NCAL Site Live
San Jose Med. Center
SelectedAsset Tracking Standard
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15
Value of Room Level Accuracy
29
15’ Distance Error - Wrong Room 2’ Distance Error – Room Level Not Applicable
5’ Distance Error - Correct Room 3’ Distance Error – Wrong Room
Enterprise Reporting Goals
• Optimize equipment inventories by site, region, enterprise, etc.o Opportunities to reduce excess purchasing
o With improved visibility, start to identify largest aggregated overages/shortages and prioritize them first
o Use overages to address shortages enterprise wide
o Minimize time from request for additional equipment to decision
• Find equipment that migrated
• Better national / regional program planning
30
Enterprise DB
Medical Center A
Medical Center B Medical Center C
Medical Center D
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16
Enterprise Reporting Versus Local
31
Local Reporting Enterprise Reporting
Reporting ScopeSingle hospital with support
buildings
All buildings by hospital
including support buildings
Target coverageSelective; hospital, then
prioritized buildings
All hospitals and medical
offices
Support for national purchasing,
project planningLimited Yes
Identify unofficial equipment
migrationsNo Yes
Data consistency Helpful Critical
Coverage consistency Helpful Important
Location consistency Helpful Important
Enterprise system integration
readinessUnlikely Critical
Differences
Requirements
Temperature MonitoringAutomated Temperature Logging and Notifications
• Temperatures logged and reported automaticallyo Medications • Blood Bank • Specimens • Breast Milk •
Solution Warmer • Food/Nutrition • Glucose Tolerance • Pathology • Blanket Warmer
• Corrective actions logged for out of compliance readings
32
• Notifications automatically sent for rising (or falling) temperatures to prevent loss and increase patient safety beyond regulatory requirements
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17
33
Radio Frequency Objects Identified “Making Counting Count”
• Improve accuracy & reliability of counting by detecting retained gauze surgical items
• Improvements in Culture of Safety by augmenting Highly Reliable Surgical Team (HRST) practices with Technology
Retained Foreign Objects
Zero Gauze-Related RFOs since early 2013 Go-Live
Now, exploring expanding to non-Gauze RFOs.
Team Simulation to Evaluate
Potential Vendors
Facility Based Pilots To Test Product &
Processes
Rapid Launch &
Rollout
Unified RFID VisionIn the operating room today, multiple RFID tags = multiple, competing sensors which lead to erroneous readings and confusion for clinicians
34
Problematic RFID example Our Vision One sensor supports multiple tags
sensor
tag
Vendor 1
Vendor 2
Vendor 3
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18
Summary of Lessons Learned• Reduces a burden on employees who spend time finding
equipment.
• Medical equipment maintenance goals are more easily achieved.
• Room level accuracy is of great importance to part time users; to keep it simple and easy to understand.
• Provides more accurate information on real time equipment quantities for hospitals, MOBs and for roll up reporting.
• Enterprise data consistency will promote roll up reporting and less complex integration work.
• Reduces equipment loss while helping to provide information on how equipment is lost.
• Enables 24x7 temperature monitoring with notifications
• Design the location infrastructure assuming multiple use cases
• Future looks bright – a lot of potential for quality improvements
35
36
Joint Learning Session with
Frontline Staff
To collaboratively learn about RTLS and explore how it might improve our work
on the frontlines
11/27/2013
19
37
Use Case #1: Summoning Staff
for In-room Assistance
Current State
Nurses often need in-room assistance from other staff for such tasks as patient repositioning and medication witnessing. To receive this help, they must leave the patient room and spend time searching for staff throughout the unit.
With all nursing staff wearing RFID badges, the technology can allow a single RN to know who is nearby, and then summon that individual to assist in patient care activities.
Win: Saved Time
Future State
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20
39
Asset Management: Key Financial and Clinical Outcomes
Tracking
• Improve Staff Productivity | Minimize Risk (Recalls, PMs, Sterile Process)
Rentals
• Control expenditures
Utilization
• Optimize inventory levels
Shrinkage
• Reduce lost, misplaced, stolen
Temperature Monitoring
• Actively monitor | Reduce loss or misuse of temperature sensitive asset
40
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21
Tracking Capabilities
41
The interface is intuitive, offering simple, one-click
searching capability
Staff can see exactly where equipment is located –anywhere throughout the facility using any network-connected computer
Understanding Equipment Misuse and Root Cause
Opportunities:• Compliance / Monitor /
Alert
• Optimize workflow, e.g. identify bottleneck area / type
• Reduced dwell time: cost savings on reduced asset inventory
• Best Practice: Aggregated results and ranking from multiple customers
42
Fluid Pump State Changes (10% Procedure Violations)
Patient
Room
(2d)
Clean
Hold
(9hr)
Dirty
Hold
(7hr)
Cleaning
(1d)
2%
1% 0%
5%
15%
11% 12%
14%18%
19%
1%
1%
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22
Automated Equipment Flow Audit Trail
Opportunities:• Compliance / Monitor /
Alert
• Optimize workflow, e.g. identify bottleneck area / type
• Reduced dwell time: cost savings on reduced asset inventory
• Best Practice: Aggregated results and ranking from multiple customers
43
Fluid Pump State Changes (10% Procedure Violations)
Patient
Room
(2d)
Clean
Hold
(9hr)
Dirty
Hold
(7hr)
Cleaning
(1d)
2%
1% 0%
5%
15%
11% 12%
14%18%
19%
1%
1%
Safety AlertSafety AlertPCA Pump 33647 (Tag 09939)
With a status of “Dirty”
Entered 11-1105A
At 04/21/2009 14:32
Automated Workflow: Surgery
Milestones
• Quantify (track) the linear progression of the patient encounter
• Standard to all patients in a unit (e.g., all OR patients in a unit have the same milestones)
44
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23
Automated Workflow: Surgery Milestones Based on Location
Patient Flow Metrics Productivity Metrics
45
• Check in to Pre-op arrival
• Pre-op arrival to
• Patient prep completion
• Anesthesia evaluation
• Surgeon Pre-op visit
• Patient prep completion to OR arrival
• OR arrival to surgery start
• OR arrival to OR departure
• OR ready for PACU to PACU acceptance
• PACU clearance to departure
• Patient wait times across care areas
• Total patient prep time required by case type
• On-time case starts
• OR Suite turn around time
• Time duration between cases
• OR holding time
• PACU holding time
• Transport response time
• Patient duration in each care area (by procedure type)
Automated Workflow: Milestone-Driven Surgery Notifications
Patient Flow Notifications Productivity Notifications
46
• Wait time thresholds
• Incomplete preparation steps (H&P, labs, IV access, etc.)
• Ready for Anesthesiologist
• Ready for Surgeon
• Time delay thresholds for clinician assessments, preparatory steps
• Ready for Surgery
• PACU readiness to receive patient, assigned bay
• Equipment par levels (pumps, SCDs. Case carts, etc.)
• Case at risk of exceeding expected duration
• Missing clinicians for case
• Transport notification upon PACU disposition documentation
• Housekeeping notification upon disposition documentation
• Dwell time for holding patients across care areas
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24
Automated Workflow: ED Milestones Based on Location
Patient Flow Metrics Productivity Metrics
47
• Check in to Triage
• Triage to Bed
• Bed to Nurse Assessment
• Door to Doc
• Door to CT/ECG
• Order to procedure (Lab, Rad)
• Call light to response
• AMI arrival to Fibrinolytic Therapy
• AMI arrival to PCI
• (Equipment dependent) order to execution
• Total Triage time
• Door to discharge/admit (LOS)
• Decision time to discharge/admit
• MD critical care time
• Nurse time in direct care (acuity)
• Transport response time
• Total time for Radiology/CT/ Ultrasound
• Discharge to housekeeping entry
• Bed cleaning time
• Bed turnaround time
Automated Workflow: Milestone-Driven ED Notifications
Patient Flow Notifications Productivity Notifications
48
• Wait time thresholds
• Ready for nurse
• Ready for doctor
• Time delay thresholds for clinician assessments, rechecks
• Time delay thresholds for procedures (lab, rad)
• Equipment par levels (pumps, wheelchairs, etc.)
• Decision to admit without written orders
• Transport notification upon dispo documentation
• Housekeeping notification upon dispo documentation
• Dwell time for holding patients
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25
Hand Hygiene Monitoring
• Monitor compliance o Soap-and-water
o Gel-based agents
• Multiple locationso Patient care areas
o Ancillary departments (pharmacy, laboratory, physical therapy, etc.)
o Food and Nutrition
49
Hand Hygiene
50
Compliance generally below 50% of the times caregivers
Entered or exited a patient’s room
Enter RoomEvent DetectedDOCUMENT
Exit RoomNo Event DetectedDOCUMENT & ALERT
Enter RoomNo Event DetectedDOCUMENT & ALERT
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RTLS-Facilitated Process Improvement Opportunities
• Elimination of “no-value-added” steps in the patient care process
• Standardization of “time-outs” before surgery
• Avoidance of the use of dirty infusion pumps
• Patient fall prevention
• Creation of communicable disease audit trails
• Pressure ulcer prevention
51
… and in conclusion
52