Patient Safety Summit Throughput- Led Initiatives with EPIC Source Data January 8, 2014 Judy Shepard, RN, MN Director, Quality/ Bed Management Raymond

Patient Safety SummitThroughput- Led Initiatives

with EPIC Source DataJanuary 8, 2014

Judy Shepard, RN, MNDirector, Quality/ Bed ManagementRaymond Smith, MBADirector, Clinical Decision Support

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Conflict of Interest Disclosure

Raymond Smith, MBAJudy Shepard, RN, MN

Has no real or apparent conflicts of interest to report.

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Learning Objectives• Learn how Grady used the EPIC system to improve patient

throughput and communication to allow inter-professional collaboration towards a strategic goal- improving patient care.

• Hear how analysis exercises through LEAN/ Six Sigma can be used to convey and reinforce key concepts in quality improvement.

• Assess the theory behind sampling strategies and the necessity of applying appropriate statistical techniques to analyze EPIC data and make valid inferences.

• Learn tips for improving EMR adoption at the staff level.• Review methods for providing process improvement

initiatives to reduce turnaround times and optimize patient throughput efficiency.

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Grady Health System, Atlanta Georgia

• Level 1 Trauma Center in the center of the city of Atlanta• Premier Regional Academic Medical center with two schools

of medicine (Emory and Morehouse)• Operating at capacity with need to grow• 953 licensed beds; 26,000 admissions• 22 Hospital based Specialty services and• 6 NHC, nearly 620,000 patient visits• Including 300,000 Emergency visits• 4800 employees; 1000 physicians

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Our Challenge• Decrease the average LOS in the ED from

median of 7.0 hours in 2012 to 6.0 hours in 2013• Decrease door to provider time in the ED from

2.4 hours in 2012 to 1.75 hours in 2013• Decrease LWBS rate in the ED from 30% in 2012

to 15% in 2013• Improve efficiency in processing time from

decision to admit in ED to patient placement in bed. 3 hours in 2012.

Current ECC

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17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 17 Feb 17 Mar 17 Apr 17 May

Current process flowFinalized

1 Sep

25 Dec

15 Jan

18 May

VALUE STREAM MAPPING DETERMINED

"MD Order To Patient Placement" Timeline July 2012 to October 2013

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RemindersPolicies,

Procedures, & Processes

Safety Culture

External Environment

Acuity

BehaviorMulti-

disciplinary Teams

Systematic PI models

Clinical Leadership

Sufficient Staff

Knowledge

Audits & Feedback

QI Perspective

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Why does Workflow Matter?

• Understanding of “How We Care for Patients”– “Physiology” as well as “Pathophysiology” of a health care

delivery system

• Necessary to Improve the Quality of Patient Care– Fundamental to achieving desired Quality Outcomes (IOM):

• Safe, Timely, Effective, Efficient, Patient-centered

– “Lack of knowledge... that is the problem… if you can't describe what you are doing (as a process), you don't know what you're doing.” –W. Edwards Deming

• Impacts Facility, Process, and IT Design, as well as

Training, Policy, and Culture:– Must understand in order to optimally manage and improve– Critical to avoiding Unintended Adverse Consequences– IT Systems must integrate into and facilitate optimal workflow

Stead IOM/NAE (2009), Karsh AHRQ (2009)

• Checklist Manifesto– Volume and complexity of knowledge has exceeded our ability

to deliver quality consistently without a simple tool- the checklist

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Ad

mis

sio

ns

Intake Inpatient Care Disposition

Global View of Patient Throughput

Information Systems • ECIN• Invision

Emergency Department• Initiation of rapid care protocols• Streamlined triage processes• Bed-side registration

EffectivePatient

Throughput

MD Coverage• Timely discharge order• Coordination with Case

Manager/ Social Worker

Case Mgmt• Prioritize discharges• Coordinate with

Nursing/Physicians• Long stay patient

placement• Family communication

ICU/Step-down/Telemetry• Facilitation of patient transfers• Placement of

Long Stay patients Nursing Units• Coordinate with Case Mgmt• Point person for facilitation

of flow• Initiation of bed cleaning

Diagnostic Testing• Timely TAT• Scheduled inpatient testing

Guest Services• Coordination with Nursing

and ED

Environmental Services• Coordination with Bed

Mgmt and Nursing to match demand

Global View of Patient Throughput

Direct Admissions fromClinics• Screening for appropriateness• Avoid direct admissions going to the ED

External Facility Transfers• Screening for appropriateness• Requires financial clearance

Perioperative Services• Improved OR prep for day of surgery• Improved start of day activities• Improved start and TAT• Develop case scheduling process

Bed Management• Anticipatory

planning for beds• Coordination with

Case Manager for discharges

• Global view of all beds

• Physician champion to facilitate

timely discharge

Day of Discharge• Communication with

family• Nursing/Case

Manager/Social Worker support at the discharge

• Notification of dirty bed• Timely bed turnaround

2Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

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Team Charter Baseline DataRoot Cause (s)

Confirmed with Data

Cost- Benefit Analysis

Implementation Plan

Standard Operating Procedure

Value Stream Mapping

Kaizen Events(Rapid Cycle

Activities)Results

SIPOC Detailed Workflow

Voice of the Customer Pilot Results Implemented

Process Monitoring Plan

Initiate, scope, and plan the

project

Understand the current

process

Determine and verify

root causes of problems

Develop and test

improved process

Implement and

monitor improved process

Provide support for

ongoing management

of process

Define Measure Analyze Improve Implement Control

Deliverables

Six Sigma DMAIC Methodology and CDS Tools

(fact based decision making)

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12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM0

50

100

150

200

250

300

350

400

Discharge and Bed Transfer Requests per HourDischarge Orders Transfer Orders

Avg

# re

ques

ts p

er h

our

Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

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12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM0

100

200

300

400

500

600

700

ED Triage Level Volumes per Hour of Day2012

Triage Level 5

Triage Level 4

Triage Level 3

Triage Level 2

Triage Level 1

Aver

age

patie

nts p

er M

onth


Psych Eval

MVC

SOB

Suicidal Ideations

Chest Pain

0% 5% 10% 15% 20% 25%

17.3%

17.5%

19.1%

23.1%

23.1%

Grady Memorial HospitalEmergency Department

Triage Level 2- Chief Complaints

Avg. 70 patients Per hour

Resp Distress

AMS

Cerebrovascular Acc

GSW

MVC

0% 5% 10% 15% 20% 25% 30% 35% 40%

6.6%

6.6%

16.4%

29.5%

36.1%


Triage Level 1- Chief ComplaintsAvg. 5 patients Per hour

Headache

MVC

SOB

Chest Pain

Abd Pain

0% 5% 10% 15% 20% 25% 30% 35% 40%

11.0%

12.3%

16.6%

25.5%

34.6%




Abscess

Knee Pain

Leg Pain

Dental Pain

Back Pain

0% 5% 10% 15% 20% 25% 30% 35%

15.0%

15.0%

17.0%

21.9%

31.0%




MVC

Rash

Back Pain

Dental Pain

Med Refill

0% 5% 10% 15% 20% 25% 30% 35%

9.8%

14.1%

19.0%

23.9%

33.1%





20,649 cases reviewed14

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15

45

75

105

135

100

300

500

700

900

1100

1300

1500

1700

1900

Avg. Bed Request to Assign Turnaround Statistics for ED

Avg

# M

inut

es

Tota

l Req

uest

s

Source: EPIC ADT Workbench Report

2012 National Benchmark (74 min.)

Jan-2012

Feb-2012

Mar-2012

Apr-2012

May-2012

Jun-2012

Jul-2012

Aug-2012

Sep-2012

Oct-2012

Nov-2012

Dec-2012

Jan-2013

Feb-2013

Mar-2013

Apr-2013

May-2013

Jun-20130

50

100

150

200

250

300

Avg. Bed Request to Assign Turnaround Statistics for EDBy Bed Type

Med/ SurgStep DownICUs

# Av

g M

inut

es p

er M

onth

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Bed Request/ Physician Order to Patient Placed in Bed Workflow Process

MD determines status

(inpatient/observation) admit order

from ECC

ECC Resident/ Attending

notifies admit team

Admit team writes/signs admission

order

2 3

Transport delivers admitted patient to

assigned unit

InterQual process review is completed

pending request information is

accurate

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Bed Management notified within EPIC

work queue

Admissions bed planner looks on the Stat Admit board for

available bed type

ECC RN calls

report

EVS customer support is contacted for escalated priority

assignment

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4

Bed request is received

from ED physician

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Is InterQual criteria met?

Admissions Intake RN contacts MD or ED case manager,

admitting team

Is clean bed available?

Patient on Hold

In ECC

Issue discussed

Admissions intake RN requests new order (hard copy

or electronic)

No

Yes

Yes

ECC RN sees bed assignment in Epic

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8ECC Clerk calls

Transport Services or places transport

order in TeleTracking

TeleTracking assigns

transporterIf available

Does ECC RN have to transport

patient?

RN/Provider will transport patient w/

monitor

Yes

Transporter arrives to floor/

unit and patient is transported to assigned bed

Patient is placed in assigned bed

ECC RN notifies ECC Clerk to

contact Transport Services

No

Is Floor RN Available to

ReceiveReport?

Yes

Fax report viewed or report given at

bedside

No910

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No

Study period #1- 393.7 min (6.6 hrs) with 20 pts reviewedStudy period #2- 235.1 min (3.9 hrs) with 13 pts reviewed

A B C D E FG

HIJK

L

Study Period #1- From A to B (avg 10.3 min) From B to C (avg 64.3 min) From C to D (avg 103.3 min) From D to E (avg 16.8 min)

Study Period #1- From H to I (avg 179 min) From J to L (avg 20 min)

Study Period #2- From A to B (avg 9.1 min) From B to C (avg 67 min) From C to D (avg 11 min) From D to E (avg 19 min) From E to F (avg 29.7 min)

Study Period #2- From H to I (avg 69.6 min) From J to L (avg 29.7 min)

Study Period #3- From A to B (avg 1 min) From B to C (avg 56 min) From C to D (avg 127 min) From D to E (avg 15.3 min)

Study Period #3- From H to I (avg 167 min) From J to L (avg 43 min)

Study period #3- 409.3 min (6.8 hrs) with 10 pts reviewed


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+ Skills- underutilized talent

Focus of Lean: Elimination of Waste




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2· Delay in seeing patient· Inappropriate admission· Lack of required information

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· Bulk and batch orders· Delay in orders· Multiple tests ordered (diagnostics) on admission· Orders written at end of shift (bulk)· Admit team writes imaging orders which may delay admit

4· Patient transfer from floor to higher level of care· No one meets them· RN does not come to telephone for report on admitted patient

5 · Intake RN does not have enough information to assign bed

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· Multiple beds assigned at the same time interval· Clerk not monitoring pending discharges· Bed assigned but still “dirty”· Appropriate room may not be available· Admissions bed planner contacts area (ICU) staff have 15 min to call Bed Czar but hardcopy from clinic may be

delayed

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· How long does it take before patient is moved?· Batched transport requests· Patient location (often incorrect or changed prior to transport arrival· Psych patients needs coordination of both transport and security

Parking Lot Issue(s)

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· Patient discharged but is still inside room· Housekeeping is ready to clean but unable to do so. $ stops when patient discharged out of system· Bed is assigned clean but is not clean. No communication verbally and patient sent to dirty room· Admission role of clerk/ designee with admit process· RN asks EVS staff to clean “dirty” room that isn’t placed in EPIC. Each time pt. moved in EVS system, it must be logged as a discharge.· Moving a “clean” bed from one room to another “clean” room creates a “dirty” bed event· See RN ICU- communication in advance

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· Bed request is received via hard copy (Clinic Admits)· Bed request is received via external transfer request from alt. facility EX. VA to 7A and also Neuro· Inappropriate level of care may require call back for proper diagnosis.- RN will need to verify dx to ECC physician vs. care team (diagnosis discrepancy)- pending status· For VA patients, will they go straight to the floor or to the ECC? Later logged into manual and team provided hardcopy from VA (which may or may not be received)· For Trauma/Burn/Stroke patients, will they go to the ECC or straight into bed once doc is assigned· Attending/ FTE Availability

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· There is delay in seeing bed available in EPIC

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· Who calls back? And how long to call back?· Patient is not appropriate for floor and discovered in report· Bed is not truly clean and ready for report

11· Delay in transport arriving, knowledge of wait time, priority for transport· Patient not appropriate acuity


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Throughput Patient Flow Initiatives for PI

• Team assessment pull process- ICU admissions• Increase utilization of the Discharge Lounge• Preliminary Discharges the day before• Capacity plan to admit high volume/ peak time

admissions• Enhanced communication between

Attending/Residents • Increase mid-level (s) at peak times of ED volumes• Step Down Criteria for Flow/Placement Optimization

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Quality/ Performance Improvement2013 Recommendations

Pillar Recommendation(s)

People ↑ volumes of medical screenings in ECC waiting room by Mid-level providers/ Nurse practitioners

Process Blast page notification to all MD’s for priority to triage discharge patients out of critically staged beds during times of ED saturation

Quality Standardized use of evidence based order sets/ nursing care plans for high volume diagnosis level 3’s in ECC on most common chief complaints

Growth Bed availability must be operationally addressed to meet expanded need for step down/ ICUs.

Bed Management Model

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The dedicated RN Bed Czar has an overview of all beds at all times and addresses any challenges in bed placement, plans proactively for the next day and works with Nursing, PACU, Case Management, ED, Admissions, Guest Services, Housekeeping, Physicians, etc., to appropriately place patients.

Source of Admission

Admissions evaluates bed board and places patient in appropriate bed. Admissions notifies Charge RN of

admission.

Charge Nurse calls back within 10 minutes with final clean bed

assignment on the unit.

PACU, Cath Lab, other procedure areas

RN Bed Czar

Admissions CMAdmissions CM performs clinical review for appropriateness of admission

ED

Direct admissions from clinics and transfers from other hospitals

Patient Access Financial screening performed by PAR

Charge RN or Unit Designee

Admissions

PACU, Cath Lab, other procedure areasED Direct admissions from clinics and transfers from other hospitals

Each area notifies Admissions of bed need via system ~ 1 hr. prior to bed needed

Physician/designee calls admissions CM with patient clinical information and discusses plan of

care

ED CM performs clinical review for appropriateness of admission. Unit

Secretary notifies Admissions of bed need.

Report automated/faxed. Receipt of report verified and questions answered. Patient transferred w/i

30 min

Pages charge RN/designee w/ bed assignment.


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Insights and Lessons Learned

1. Must include Direct Observation, Record

2. Don’t forget the Clinical dimension

3. Repurpose Data currently in environment

4. Consider Multiple Methods

5. Focus on time or resource consuming tasks

6. Don’t miss Rare or Critical events, interruptions, workarounds, or delays

7. Simulations force detailed descriptions of work and are good for communicating with subjects and testing interventions or scenarios

8. Consider all “Systems”, their respective “Lifecycle” state, and Contextual Factors

9. Need for a Systematic, Interdisciplinary Approach to study workflow

10. Engage Leadership and Staff

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Thank YouQuestions???

Documents

Patient Safety Summit Throughput- Led Initiatives with EPIC Source Data January 8, 2014 Judy Shepard, RN, MN Director, Quality/ Bed Management Raymond