Center for Health Care Innovation DISCHARGE DESIGN …DISCHARGE DESIGN SPRINT 9/13 Possible target opportunities within discharge/patient journey. “Bed-flow is the real problem”

Center for Health Care Innovation

DISCHARGE DESIGN SPRINT 9/13 Possible target opportunities within discharge/patient journey. “Bed-flow is the real problem”

discharge documents

consistently begin here on NP floor

Rhoads 3

Information gathered from six staff interviews: Center for Health Care Innovation contact: Kate ClaytonRebecca Hirsh, MD Director, Inpatient Oncology Services Mauri Sullivan, MSN, RN Clinical Director, Medical NursingColleen R. Kucharczuk, CRNP, Lead Oncology Nurse Practitioner Beth Eaby-Sandy, MSN, CRNP, OCNSarah Longworth, MD Chief Medicine Resident Chris Klock, Performance Improvement

Scheduling “not accurate” (duplicates and

errors). Scheduling is “a huge issue”

Delays to admission due to unavailable beds: rescheduling.

Process is “infuriating” for patients

Simultaneous admissions

increases work load and makes early

discharge planning fall to wayside

Some patients admitted without

proper preparations (picc line, etc): bed unnecessarily used,

increases LOS.

Residents responsible for discharge “are not thinking about the whole process” Their focus is on learning medicine, not on moving

patient along

On 2-week rotating service, there’s“no sense of ownership.” Moving patients along

doesn’t take priority

Discharge priority “is just not part of the culture here”

Variations: each floor/services team

(and individual) has a different time they begin

discharge planning

Discharge planners are “very helpful” and yet are not always on rounds and are not a

part of every team

Patients held for reasons that would not warrant hospitalization:

increased LOS

Discharge delayed waiting for PT or lab

results

Residents busy with other tasks, ex: phone, scheduling

appointments

Discharge takes priority only after rounds & teaching

patients stay in a bed waiting for a ride home

Scheduling is not coordinated by a medical staff who

can prioritize patient needs

No load-balance: M-F

8-7-6-5-0; Mondays are overloaded

APPOINTMENT SCHEDULED

or ED or TRANSFER

Opportunity:Better scheduling

Prioritize patient needs

Opportunity:Patient Satisfaction

Opportunity:Increase Discharge Prioritization

Opportunity:Transition Services

ADMISSION TO HOSPITAL HOSPITAL STAY DISCHARGE

PROCESS


DISCHARGE DESIGN SPRINT 9/13 Possible target opportunities within discharge/patient journey. “Bed-flow is the real problem”

discharge documents

consistently begin here on NP floor

Rhoads 3

Information gathered from six staff interviews: Center for Health Care Innovation contact: Kate ClaytonRebecca Hirsh, MD Director, Inpatient Oncology Services Mauri Sullivan, MSN, RN Clinical Director, Medical NursingColleen R. Kucharczuk, CRNP, Lead Oncology Nurse Practitioner Beth Eaby-Sandy, MSN, CRNP, OCNSarah Longworth, MD Chief Medicine Resident Chris Klock, Performance Improvement

Scheduling “not accurate” (duplicates and

errors). Scheduling is “a huge issue”

Delays to admission due to unavailable beds: rescheduling.

Process is “infuriating” for patients

Simultaneous admissions

increases work load and makes early

discharge planning fall to wayside

Some patients admitted without

proper preparations (picc line, etc): bed unnecessarily used,

increases LOS.

Residents responsible for discharge “are not thinking about the whole process” Their focus is on learning medicine, not on moving

patient along

On 2-week rotating service, there’s“no sense of ownership.” Moving patients along

doesn’t take priority

Discharge priority “is just not part of the culture here”

Variations: each floor/services team

(and individual) has a different time they begin

discharge planning

Discharge planners are “very helpful” and yet are not always on rounds and are not a

part of every team

Patients held for reasons that would not warrant hospitalization:

increased LOS

Discharge delayed waiting for PT or lab

results

Residents busy with other tasks, ex: phone, scheduling

appointments

Discharge takes priority only after rounds & teaching

patients stay in a bed waiting for a ride home

Scheduling is not coordinated by a medical staff who

can prioritize patient needs

No load-balance: M-F

8-7-6-5-0; Mondays are overloaded

APPOINTMENT SCHEDULED

or ED or TRANSFER

Opportunity:Better scheduling

Prioritize patient needs

Opportunity:Patient Satisfaction

Opportunity:Increase Discharge Prioritization

Opportunity:Transition Services

ADMISSION TO HOSPITAL HOSPITAL STAY DISCHARGE

“TIME TO CHEMO” LIQUID ELECTIVE PATIENTS

DISCHARGE DESIGN SPRINT 10/13 Delays in Patient time-to-chemo for elective patients


delays before bed is available:

at capacity

delays after in bed

uphs not ready

waiting for operating

hours

waiting for staff

patient not ready

picc line and other preparations not

complete

patient lives far and we prefer

prep here

can’t be done prior if no

guaranteed bed

patient not prepared

because bed availability date

uncertain

increasing demand for services

other patients occupy beds

patients get rescheduled

less priority than urgent/emergent

patients who need that bed

delays: waiting

for treatment

for labs or ptfor discharge to be

decided

variations in start of chemo

variation in available hours

weekends

discharge is one

of many tasks for

staff

support services only

open 7-7

variation in teams

oncologist vs hospitalist

discharge occurs after rounds and

after teaching

for dischargefor logistics:

ride

lack of beds

patients who don’t need that bed

no guarantee of bed on

required day

doesn’t need onc bed but needs to be

monitored

inpatient bed used for treatment that could be outpatient

terminally ill patient still in the bed

must take a bed because infusion/

outpatient suite closes at 7

hard to discuss end of life

culture and training

less priority than other longer waiting

elective patients

urgent patients take priority

too many bookings on same day

calendar not dynamic

scheduling not coordinated

no real-time live calendar:

technology

no one who owns/manages calendar for

oncology

root problem

analysis

suggested solutions

increase bed or speed?

hire person to manage calendar

and talk to floors re discharges

speed

improve calendar

technology

speed

write transfusion orders and send in with

patients

speed

designate beds just

for elective

speed

reduce variations

between days of week

speed

increase hours

of service

speed speed speedspeed

add admin person to fax,

phone assist discharge

speed

decrease current

staff demands

allow residents or admin to log in

to patient’s mypennm

speedspeed

aid in departures

think as system:

use presby

speed

schedule all possible as outpatient

bedbed

begin end of life talks sooner

guarantee bed for required

day (only)

bed bed

marketing

we make

money

we’re good at what

we do

evenings & weekends

variation in teams

discharge is one of many

tasks

increase hours of

operation/services

add admin person to fax, phone

assist discharge

send chemo orders in with patients

discharge is one of many tasks

staff attending to other demands

post-admitpre-admit

type of need

evenings/weekendsevenings/weekendsevenings/weekends

technology

procedureprocedure procedure procedureprocedure procedureprocedureprocedure

operations operations operations operations operations operationsoperationsoperations operations

staffstaff staffstaff staff staff staffstaff staffstaffstaff staffstaffstaff staff

qualities of solution

Overviews of all oncologyHelps us to plan ahead

Helps us prioritizeApproves the # of slots that can be scheduled per day

Manage relationships & requests within oncologyScheduler has clinical understanding

Uses epicLiving document

Updated in real timeNo duplicates

Can dynamically move patients in schedulePreserves bed for scheduled patients

Discharge starts earlier in day/stayAdds to culture of discharge

Supports residentsSomeone to say “where are we”

Increase medical staffSaves time for residents

Lowers barriers for scheduling for patientsReduce time from end of chemo to open bed

Uses new resources like hotel vouchersMore beds!

Chemo starting in clinicHave more staggered chemo

Save beds (reduce admissions) Patient space serviced by needs

Patients satisfactionThink as a system

Saves bedsDecreases time to chemo Chemo can start any time

Contextual Inquiry: clinicians and staff, liquid & solid, outpatient/inpatient, TAC, etc. RCA. Systems. Crowdsourced ideas. Solutions types & qualities.

PROCESS

S/E

M FTWT

Ur. Em.

+ TRANSFERS

HUP

T A C

Scheduled/Elective, Urgent, & Emergent admissions, compounded by transfers,are all sent as Admissions requeststo The Admissions Center

2 solutions can consolidate the most needed qualities.

SOLUTIONS TO TEST:

CURRENT SYSTEM:

IN ESSENCE:

There is no oncology-wide system that schedules patients based on clinical needs, load balances demands, optimizes outpatient potential, prepares patients before admission, or manages bed-flow management. Result is constant rescheduling that potentially affects dose intensity and outcomes.

19

1) a clinician to prioritize and load balance patients based on clinical needs

2) to reduce length of stay by scheduling all possible outpatient treatments as such (mixed regimen)

3) to coordinate patients before hospital admission with all necessary preparations to reduce time-to-chemo

Manage bed-flow,reduce scheduled bed demand,prepare patients

3 MAIN GOALS:

A: ONC ADMISSIONS STAFF

3

1

2

EZ Pass

S/E Ur. Em.

+ TRANSFERS

M FTWT

HUP

T A C

O N C A D M I S S I O N S

OUTPATIENT

CAPACITY

TIME

BED DEMAND

1: LOAD BALANCE2: REDUCE LOS BY SCHEDULING OUTPATIENT3: REDUCE LOS BY PREPARING PATIENTS

12 3

ALTERNATIVE VIEW: A

Manage bed-flow,Reduce scheduled admissions,Prepare patients

3 MAIN GOALS:

1) to prioritize and load balance patients based on clinical needs,

2) to reduce length of stay by scheduling all possible outpatient treatments as such (mixed regimen)

3) to coordinate patients before hospital admission with all necessary preparations to reduce time-to-chemo

In parallel to current system, schedule with prototypes to test these metrics:

What are the Metrics?1.“Minimize the time from scheduling to chemo”2. Reduction of rescheduled admissions (delays), 3. Reduction of LOS for scheduled admissions

What tools does this person need? 1: A unified system of prioritization, co-created from clinicians who schedule patients2: An organizational calendar method to balance demand.

Minimum Viable Product

O N C A D M I S S I O N SEXPERIMENT

A: HOW MIGHT WE TEST?

For example: Patient Smith is scheduled for Regimen X, with a 4 day window for acceptable admission, beginning November 10th:

Nov 10:

Scheduling by range:

Patient J. SmithRegimen XEarliest Date: Nov. 10Latest Date: Nov. 14Time window: T-4

EXPERIMENT:

Nov 11: Nov 12: Nov 13: Nov 14:Nov 10:








EXPERIMENT:

Each day after the start date, Time - # ticks up one day:

The aim is to schedule patients with the highest T-# possible (T-4)

Urgent and Emergent patients always present at T-0

Mixed inpatient/outpatient Regimens are T-0 on required hospital days

Nov 11: Nov 12: Nov 13: Nov 14:Nov 10:



Patient EmergentIndicationEarliest Date: todayLatest Date: todayTime window: T-0

Patient Regimen X MIXEDEarliest Date: todayLatest Date: todayTime window: T-0






EXPERIMENT:

Each day after the start date, Time - # ticks up one day:

The aim is to schedule patients with the highest T-# possible (T-4)

Questions in prototyping:

What algorithm can we use to determine treatment window?

What’s the best day to schedule mixed regimens?

What is the process for making sure scheduled patients have all preparations ready?

How many beds did we save?

Who does Onc Admissions talk to on the floors?Aha! MVP testing leads to discovery: other tools that can be

implemented, and methods on how Onc Admissions can best work with other HUP/PCAM teams.

A calendar prototype: the best prototypes aren’t fancy!

EXPERIMENT:

Uncomplicated patients at Infusion and Outpatient appointments increase urgent and emergent bed requests.

To assess, identify, and offer intermediate levels of outpatient care,To reduce urgent and emergent admissions,To increase outpatient services

WHAT HAPPENS NOW:

B: URGENT CLINIC

Ur. Em.OUTPATIENT

TIME

ACUITY/ LEVEL OF SERVICES

7am 7pm 12am12am 12pm

H U P

INFUSION

E D

CURRENT PATIENTS’ JOURNEY

1) To triage patients to their appropriate level of care

2) To offer this intermediate care: fluids, blood products, vitals, labs, IV medications, etc.

3) Reduce HUP admissions by providing outpatient services, and bypassing the ER for HUP-required admissions.

To assess, identify, and offer intermediate levels of outpatient care,To reduce urgent and emergent admissions,To increase outpatient services.

B: URGENT CLINIC

3 MAIN GOALS:

CARE CLINIC

OUTPATIENT

TIME

ACUITY/ LEVEL OF SERVICES

7am 7pm 12am12am 12pm

H U P

INFUSION

E D

FUTURE PATIENTS’ JOURNEY

HOW MIGHT WE TEST?EXPERIMENT:

PROTOTYPE: A form for providers who would use an urgent clinic

Imagine we have a 24 hour urgent clinic that can provide outpatient services to patients to avoid admissions to the ED and HUP. This clinic can evaluate a patient, provide fluids, blood products, labs, IV medications, check a CBC, give transfusions, give a neupogen shot, and check vitals.

If we had this clinic, I

could have sent

to the urgent clinic for

The patient would likely use the clinic for

provider name

patient name

indication

time of day date

hours

Note:

This would avoid a patient being sent to the ED only

This would save a hospital admission altogether

1. Vapor test—Offer something that hasn’t materialized yet:Give a form to clinicians who admit patients from Infusion or Outpatient services: For each patient, if we had a clinic, who would they send there?

Track patients from above list: could that patient have been satisfied by clinic services? Did they develop into greater acuity, or could they have avoided ED and HUP?

2. One night stand —try it before you commit: Based on demand from above, add services to the Infusion suite as a moonlit clinic, or reserve Observation Unit beds as urgent clinic for patients who present during outpatient visits and could avoid admission.

Experiments to test solutions to plan for greater success

EXPERIMENT:

If we knew something 2-3 days ahead of the time that urgent and emergent patients presented: would it be helpful? Could we intervene?

For example, could we provide hydration patches for remote monitoring?

Are there other methods we can employ to reduce cases of nausea, fever, etc, before patients present?

Looking at the root causes of urgent presenters to further identify reasons for bed demand.

WHAT IF WE KNEW...

OTHER IDEAS

Ur. Em.?

Rapid prototyping can help us to quickly discover specific criteria for creating robust solutions that address needs and qualities across oncology.

MVP parallel scheduling will help determine how onc admissions will best be executed. A schedule window range and calendar prototype will help determine how to load balance, prepare patients, and mix inpatient/outpatient regimens.

In addition to current pilot, “Vapor testing” with surveys and “one night stands” will help gauge group demand and potential.

What can we forecast in the future of oncology? Let’s test new ideas to improve bed-flow and patient experiences/outcomes, and increase our service efficiency.Ex: BMT as mixed inpatient-outpatient: testing these ideas to lead to earlier implementation.


BMT? 2023

RECAP

B: URGENT CARE

C: FUTURE NEEDS

A: ONC ADMISSIONS

CARE CLINIC

H U P

INFUSION

OUTPATIENT

E D

Oncology & AdmissionsRebecca Hirsh, Mauri Sullivan, Regina Cunningham, Matt Goldstein, Colleen Kucharczuk, Beth Eaby-Sandy, Sarah Longworth, Sunita Nasta, Tonita Chapman, Michelle Cannon, Ella Ryan-Meloni LeadershipLisa Bellini, Neil Fishman, PJ Brennan, David Horowitz

InnovationKate Clayton, David Asch, Roy Rosin, Shivan Mehta, Raina Merchant, Amanda Christini, Jen Myers, Adam Lang, Matthew Van Der Tuyn, Katy Mahraj, Emilie Bartolucci, Derek Mazique

Let’s move these ideas forward!

Oncology bed-flow can be improved by consolidating qualities into:an oncology-specific scheduling/admission process, anda higher utilization of outpatient services.

THANK YOU

CONCLUSION

Documents

Center for Health Care Innovation DISCHARGE DESIGN …DISCHARGE DESIGN SPRINT 9/13 Possible target opportunities within discharge/patient journey. “Bed-flow is the real problem”