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Patient Admission from ED to Acute Care
Tech 581: Improve/Control Presentation
December 9, 2008
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Brief review of project: Patient Admission from the ED to Acute Care
The aim of this process is to reduce the lead time for safe and timely patient admission from the ED to Acute Care services. By improving the efficiency of this process, the organization will improve their accessibility, capacity, patient safety, quality of care, and patient and staff satisfaction. The primary target of this process improvement effort is to decrease patient length of stay in the ED from the time an admission order is written.
As health care moves into the era of reporting quality indicators; improving quality of care and patient safety rankings will positively affect the organization’s reimbursement rates. The consequences of not improving the efficiency of this process are reduced quality and patient safety (and possibly reimbursement rates), increased costs associated with increased elopement rates, and lost revenue as a result of increased time on diversion. Therefore, it is important to improve this process now in order to maintain reimbursement, control costs, and prevent losing revenue.
SIPOC Suppliers Inputs Process Outputs Customers ED physicians Admission order
PROCESS:
ED admission order to in-patient admission
Patients admitted to in-patient bed
ED physicians
ED nurses & Director
Bed placement assignment
ED nurses & Director
PCU/ICU/Med/Surg unit nurses & Directors
Equipment (IV pump) PCU/ICU/Med/Surg unit nurses & Directors
Lab/ImagingTechs & Directors
Lab/Imaging results Lab/ImagingTechs & Directors
Bed Placement staff & Manager
Supplies (oxygen, bed pans, etc)
Bed Placement staff & Manager
Admitting physicians
Admitting physicians
Vendors (IV pumps)
EMS
Environmental Services staff
Patient
EMS Patient families
Transport team
VoC – SWOT AnalysisStrengths Advanced, automated bed tracking and patient transfer system in place High level of physician and nurse expertise Department Directors with a wide range of experience and knowledge Support from the Executive Leadership Team Available resources to accommodate changes Addition of Transport Team has been very helpful
WeaknessesAnimosity between departmentsCommunication barriers (i.e. personality conflicts) between departmentsPerceived inadequate staffing levels (i.e. nurse/patient ratio)Departments operate in silosLack of awareness of other department processesLack of standardized directions for admission orders and bed requestsLack of standardized directions for when order/request should be made (i.e. before or after lab/imaging tests and results)
VoC – SWOT Analysis
Opportunities Improve communication between departments Create a team-oriented culture Educational sessions highlighting department-specific processes Standardize admission order/bed requests across respective departments Use the automated system to capacity
Threats Increased animosity between departments Pushing staff too hard in a high-stress environment Staff retaliation and push-back towards management Disrupting the flow too much could jeopardize patient safety Decreased quality of care without improvement Increased diversion time and reduction in revenue capture Increased elopement rates and associated costs Poor quality and safety ratings could lead to reduced reimbursement rates
16. CTQ Tree
CTQ KPIVs Customer(s) KPOV(s)
Dept. Directors
Bed Placement Manager
ED Physician
Unit Nurse
Patient
Pt. families
Patient admission time
Time between admission order written and time bed request is made
Time between bed request and patient admission to unit
ED staffing levels
Ordering protocol
Communication process b/w ED staff and Bed Placement staff
Unit staffing levels
Bed turnover time
Lab/imaging result time
Patient transport and admission protocol
Communication b/w Bed Placement staff and admitting unit
ED physician completes admission order
ED staff faxes copy to Admissions & sends elect copy to Bed Placement
BP triage order & check bed availability
Bed ready? BP makes request to unit
Pt waits til ready
Pt arrives; unit notifies Admissions to admit patient
Order sent on time
Lab ready
Incomplete request
Complete comm. b/w ED & unit
Current State Process Map; from measure phase
Patient #10
Step # Description Clock timeTask time (min)
Wait time (min) Observations
1 Ed phys completes admission order 21:21
2 ED staff fax copy to Admissions & elect copy to BP 22:19 2 56
Order not sent on time
3 BP triage request & ck bed availability 22:24 5
4 Bed ready?5 if No6 BP makes request to unit 22:25 17 Pt. arrives; unit notifies
Admissions to admit pt. 23:00 15 20 lab not ready
Total 99 min 23 min 76 min
Process Observation Worksheet (e.g.)
Checksheet
Project Name: Patient Admission from ED to Acute CareOutput Metric: Time from order in ED to patient arrival in Acute Care
Date patient # Order madebed request made
time lapse (min)
pat. Arrival in acute care
time lapse (min)
total time (min)
total time <= 50 minutes reasons for delays
10/7/2008 1 1439 1439 13 1455 16 29 Y10/7/2008 2 1440 1505 25 1515 10 35 Y10/7/2008 3 1935 1940 5 2025 45 50 Y10/7/2008 4 1030 1044 14 1155 71 85 N bed not ready10/7/2008 5 1544 1612 28 1653 41 69 N incomplete request10/8/2008 6 1850 1856 6 1952 56 62 N lab order not ready10/8/2008 7 1934 2010 36 2029 19 55 N bed not ready10/8/2008 8 2235 2420 135 2451 31 166 N incomplete request
10/8/2008 9 1827 1950 83 2013 23 106 Npoor communication b/w ED and admitting unit
10/8/2008 10 2121 2225 64 2300 35 99 N Order not sent on time; lab not ready
10/9/2008 11 1418 1520 62 1533 13 75 Npoor communication b/w ED and admitting unit
10/9/2008 12 1957 2050 53 2150 60 113 N Order not sent on time10/9/2008 13 2038 2123 45 2203 40 85 N lab order not ready10/9/2008 14 830 850 20 910 20 40 Y10/9/2008 15 1224 1252 28 1315 23 51 N lab order not ready
10/10/2008 16 1956 2052 54 2109 17 71 Npoor communication b/w ED and admitting unit
10/10/2008 17 2142 2148 6 2225 37 43 Y
10/10/2008 18 2311 2350 39 16 26 65 Npoor communication b/w ED and admitting unit
10/10/2008 19 2348 40 52 107 27 79 N bed not ready
10/10/2008 20 730 853 83 944 51 134 Norder not sent on time;bed not ready; lab not ready
ED patient room ED patient room
ED patient room
ED patient room
Computer kiosk
Computer kiosk
Spaghetti Diagram
Data Collection Plan; measure
Time (min) from the time an admission order is made in ED to the time a bed request is made
Time (min) from the time request is made to patient arrival in Acute Care
Reasons for delays will ultimately identify new KPIVs Data collected for 8 week days over an 11 day period (10/7 – 10/17) Collected data on 5 patients/day over 8 days = 40 patient sample
size Will graphically present:
Average order to request time/day Average request to placement time/day Total average time/day
ED order to Acute Care arrival
0
20
40
60
80
100
120
140
160
Date
Tim
e (m
in)
Avg order to request time/day
Avg request to placement time/day
total avg time/day
Data Collection Plan Cont… (analyze) Graphically present the distribution of total time, for sample data,
from Admission Order to patient arrival in Acute Care unit Further breakdown of data; identify which step(s) are contributing
the most to overall time Column chart: % contribution to overall time of each step Pie Charts: distribution of reasons for delays
Anecdotal information/data used to eliminate KPIVs
Total Time (mins)
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Patient #
Tim
e (m
ins)
total time
Distribution of total times from Order Written to Pat. Arrival in Acute Care
% Contribution to overall time of each step
0%
20%
40%
60%
80%
100%
% Contribution
total avg time/day
Avg request to placement time/day
Avg order to request time/day
10/1710/1610/1510/1410/1010/910/810/7
% of sample that was admitted in goal time (<= 50 mins)
Percentage Admitted in <= 50 mins
15%
85%
# pats admitted in goal time
Total # of patients
% distribution of reasons why patients were not admitted in goal time
Reasons for Delays
35%
23%
42%
Bed not ready
Lab not ready
poor communication/order not sent on time
Improve PhaseInformation to eliminate KPIVs; (refresh from Analyze) Transportation is not an issue: the hospital has
successfully implemented a transportation team Lab Delays: Recently implemented I-Stat; software that
will produce lab results in 5 minutes Ordering and admission protocol/communication:
subject to patient census and unit staffing levels PCU 3:1 patient to nurse ratio – regulated ICU 2:1 patient to nurse ratio – regulated ED 8:1 patient to nurse ratio – not regulated ER census increased by 8% this year Budgeted for 118 pts/day; currently 134 pats/day
Conclusions
Following thorough examination of KPIVs; Bed turnaround, staffing levels, patient volume are the main reasons for delays in the KPOV (Patient Admission Time)
Lab results delay is being rectified Communication/ordering/placement protocol significantly
affected by staffing levels and patient volume Bed turnaround time is all that is measurable; delays in
turnaround time stem from poor communication b/w unit nurses and Env. Svcs staff
List of Solutions; Eliminate Impact of Bed Turnaround Time (used multi-voting)
1. Implement electronic signaling system for env svcs to notify unit nurses/transport team when bed is clear
2. Staff training/education; Team building and prompt communication; everyone knows how his/her duties contribute to overall success of decreased patient admission time
3. Hire more env svcs staff4. Add more Acute Care beds
Solution Matrix
KPOV: Patient Admission Time Solutions
KPIV:RPN
Electronic signaling
#1
Staff educ/train
#2
Hire env svcs staff
#3
Add acute care beds
#4
Bed Turnaround Time 8 9 6 5
Total Impact 8 9 6 5
Success Criteria:
Patient Safety
Likelihood of Success 7 8 5 4
Cost ($$) 6 10 (lowest) 5 4 (highest)
Staff Satisfaction
7 9 5 5
Quality of Care
6 10 6 5
Patient Satisfaction
7 10 5 5
Success Criteria Total
33 47 26 23
Total Score 41 56 32 28
5
3
1
1 3 5
Effort
IMPACT
#1 Electronic signaling
#2 Staff educ/training
#3 Hire env svcs staff
#4 Add more beds
Impact/Effort Matrix
ED physician completes admission order
ED staff faxes copy to Admissions & sends elect copy to Bed Placement
BP triage order & check bed availability
Bed ready? BP makes request to unit
Pt waits til ready
Pt arrives; unit notifies Admissions to admit patient
Order sent on time
Lab ready
Incomplete request
Complete comm. b/w ED & unit
Current State Process Map; from measure phase
Future State Process Map
ED physician completes admission order
ED staff faxes copy to Admissions & sends elect copy to Bed Placement
BP triage order & check which bed is available
BP makes request to unit
Pt arrives; unit notifies Admissions to admit patient
Requirements:
Education/training improve promptness/communication/turnaround time/complete order
I-Stat implementation to alleviate lab delays
Pre-Pilot Planning Checklist
Timelines and Plans:Item Owner/Completion
Date
Y N
Deadlines and responsibilities for prep work have been determined.
12/1
Y NDeadlines for stopping and starting the pilot exist.
12/3-12/15
Y NBudgets and required resources are outlined for approval.
champion
Y NDaily review meetings for review of pilot data have been scheduled.
Directors
Y NIn-services with front line staff have been scheduled.
Directors
New procedures:
Y NNew procedures are documented with flow charts and written instructions
Directors
Y NOther necessary materials (list in comments sections) are prepared.
Y NPilot Control Plans developed and outlined for approval.
Directors
Stakeholder preparation: Item Owner/Completion Date
Y NEveryone involved in the new process understands his/her role and responsibilities
Directors/staff
Y N In servicing conducted. Directors/staff
Y N
Anyone outside of the main stakeholder group, but impacted by the process changes has been informed of the test stop and start date/time and the process changes.
Lab/imaging
Pilot Data Collection:
Y NProcedures are in place to monitor both methods and results.
Team members/directors; use measure checksheets
Y NData collection plan allows for evaluation of changes to key indicators
Y NPlans allow for containment if process metrics and/or procedures respond negatively to changes.
By the end of the Pre-Pilot Improve phase: Item Owner/Completion Date
Y NA list of innovative potential solutions has been generated
12/1
Y N
Improve tools (solution matrix, impact/effort matrix) were used to narrow the solution list and to further develop and quantify solutions.
12/1
Y N Success Criteria were established 12/1
Y N A final solution was chosen based on impact to success criteria. 12/1
Y N Solution is presented and approved by the Champion team. 12/1
Y N Pilot and pilot control plan is developed. 12/2
Y N Pilot is approved by the Champion team. 12/2
Y N Tollgate preparation
Pilot Implementation Plan
Inform key stakeholders (Unit Directors, Env. Svcs, BP Manager, Lab/imaging) of the schedule and plan
Staff Team Building Education/Training: Focus is how each staff members role directly contributes to the overall success of decreasing patient admission time (gives sense of involvement/importance)
Pilot Implementation: track patient admission time (more specifically, delays to bed not ready/poor communication) using process observation worksheet from measure phase.
Set daily meetings to review progress toward decreased admission time as a result of staff education/training
Control PhaseStandardized Processes and Immediate/Long-Term Control Patient Training/education geared toward effective team building
and stressing the importance of prompt/correct communication will help standardize staff actions and accountability
Training/education will result in elimination of delays and allow for a standardized flow process as illustrated in the Future State Process Map
Immediate control: daily tracking of Patient Admission Time (KPOV); daily tracking of bed turnaround time (KPIV) using observation worksheet
Long-term control: Training/education becomes engrained in the culture and allows for the implementation of electronic signaling, adding more beds
Control Plan
Project Title: Patient Admission from ED to Acute Care
Metric KPOV/KPIV Target Collected by Frequency Method Graphing Review
Order to bed request KPOV 10min
Director/unit nurse 75%, Daily manual run chart daily, 5pm
Request to Admit KPOV 35min
Director/unit nurse 75%, Daily manual run chart daily, 5pm
Total time KPOV <50minDirector/unit nurse 75%, Daily manual run chart daily, 5pm
Bed Turnaround Time KPIV <39min
Env. Svcs/BP Manager 75%, Daily manual run chart daily, 5pm
Action Plan
Director will track the reasons for delays in bed turnaround time
For each patient falling outside the desired metric; will then focus training and education on ways to correct those delays
Cost Benefit AnalysisBy improving the efficiency of this process, the organization will improve their accessibility, capacity, patient safety, quality of care, and patient and staff satisfaction. A considerable amount of leadership and staff time will be needed to educate and train the staff, and measure and track the results. Therefore, a significant investment in staff salary will be necessary to improve the process.
The downstream benefits of improving the process will significantly exceed the initial investment in staff salary. The benefits include: Increased revenue gain as a result of decreased diversion time (lose $1800/hr when go
on diversion) Decreased costs associated with decreased elopement rates Increased capacity to see more patients in the ED Improved physician and staff satisfaction leads to recognition as an employer of choice Improved patient satisfaction leads to more patient referrals Improved quality and safety rankings
Team Recognition!!
Write-up on the intranet displaying some of the work (graphs/diagrams/analysis) to show appreciation to team members
Invite all team members to attend recognition lunches Include a spot in the organizations “Best of Class” exhibit
to honor and recognize the team’s work and commitment to improving the quality of care
Diffusing the Improvements
Promote success through exhibit in “Best of Class” Distribute a newsletter illustrating the importance of
improving quality of care in this time of reporting quality indicators (increased reimbursement and recognition as employer of choice)
This project can be spread throughout the network if it is part of a system (which this particular hospital happens to be)
Also, a similar project could be conducted on the back end which focuses on improving the efficiency of discharging patients from the hospital (or hospitals in the network)
