Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months

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Increasing ED and Hospital CapacityTop
Initiatives for Dramatic Results in 6 Months

• Presented by
• Michael B. Hill, MD, FACEP
• January 10, 2003
• On Our Watch
• Illinois College of Emergency Physicians

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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Why Dont Hospitals and EDs Work?
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Barriers to Top ED Performance

• Caregivers have unclear vision on how to meet
  conflicting needs of emergency and unscheduled
  medical care
• Most EDs are not set up to deal with predictably
  unpredictable arrival times of ED patients.
• Organizational culture is one in which we do not
  ask for help
• Unclear when to do it
• Unsure who to ask
• Variable response to request

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Barriers to Top ED Performance

• Variable integration of ED operation with
  inpatient delivery systems
• Varying degrees of sophistication in defining
  operational metrics
• ED as significant revenue driver is not
  articulated/understood by key constituencies.

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Key Finding Confirms Central Challenge to
Hospital Capacity Issues

• Bottom quartile performance for key operational
  tasks that affect inpatient intake/discharge and
  ED performance
• Explains heavy resource utilization
• Indicates unclear ownership, accountability, lack
  of operational metrics, significant process and
  unit variability, and lack of backup systems

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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Traditional Approach for Improvement

• Well fix the ED if you give us more
• Space
• Staff
• Information technology
• We cant fix our ED due to
• Demographics of our population
• Unpredictable volume surges

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Traditional Change Process Initiation Based on
Tactical Initiatives

• Testimonial
• Anecdote
• Manager has an idea
• Strategic initiative rare

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Why ED Physicians Think of Solutions as Tactical
Initiatives

• Primary tool we use for CQI
• Does not require hospital leadership buy-in or
  approval.
• Minimal budgeting impact.
• Few resources to identify desired behavior.

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Major Problems with Tactical Initiatives

• Leadership not brought into process prior to
  implementation
• Not enough resources to
• Develop solution
• Communicate solution
• Inspect to ensure proposed change is actually
  completed
• Staff not brought into development process
• No measurement systems
• No inspection for desired behaviors

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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Team Based Care

• Assign hospital and unit ownership and
  accountability
• Give tool sets and skills to owner for success
• Use multiple processing units
• Reduce set up / start time
• Deliver staff consistently
• Set up real time communication system

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Metrics Driven Management

• Develop operational definitions and goals
• Reach agreement on expectations. Then hold
  managers and staff accountable
• Monitor data on a weekly basis database
  management
• Give people access to the data
• Hard wire specific next step activities based on
  results

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Major Problems with Metrics

• Key performance indicator identification
• No defined targets
• Acuity selection
• Removing outlier data
• Start / stop points
• Sample size
• Ownership not identified

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ED KPIs and Owners
KPI Owner
Overall LOS Admit, Discharge, Overall Charge Nurse
Arrival to Bed Placement Charge Nurse
Bed Placement to MD Exam ED MD/CN
Lab TAT Blood/Urine CN/Lab Superv
Radiology TAT Plain/Specialized CN/Rad Superv
Bed Request to Patient Departure CN/House Mgr
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Inpatient KPIs and Owners
KPI Owner
Direct Admission Arrival to Departure Admit Superv/ House Mgr
Bed Control Request to Pt Departure BC/House Mgr
Pt Intake Bed Assigned to Pt Arrival CN/House Mgr
Pt Discharge MD Discharge Order to Written to Bed Ready CN/House Mgr
Housekeeping Pt Departure to Clean Initiation CN/HK Superv/ House Mgr
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Reduce Cycle Time

• Achieving target goals by
• Moving from push to pull systems
• Being absolutely ruthless in eliminating
  variation
• Defining clear transition steps from each
  provider to the next
• Delivering work consistently
• Defining time expectations for common task
  completion
• Hard wiring triggers and backup systems

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Push Systems Scope of the Problem

• Current process owner responsible to get patient
  to next step
• Individual ownership encourages innovation,
  negotiating skills and rewards variability
• Variability in task accomplishment means that
  most tasks are sequential
• High utilization of resources required to
  complete tasks
• Predictably breaks down when busy due to lack of
  defined back up system
• Almost all hospital intake and discharge systems
  are push systems

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Pull Systems Why We Want Them!

• Next Step process owner responsible to ensure
  patient receives next step
• Defined expectations of other staff decreases
  variability and encourages consistency (hand
  off)
• Decreased variability allows parallel processes
  to stabilize
• Processes keyed to Key Performance Indicators
  ensure consistent work effort regardless of
  census
• Well defined backup systems can tolerate volume
  surges
• Top performing hospitals use pull systems

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Learning Organization

• Explicit training and orientation program
• Performance evaluation explicitly link
  constituency specific behavior to key performance
  indicators

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Stakeholder Loyalty

• Passionate, single mindedness to customer
  outcomes
• Achieve target goals

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Healthcare Change How to Design Change

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Weve Tried to Fix the ED Before And

• Bad News
• Tactical initiatives rarely create signifi-cant
  overall length of stay improvement.

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Even Successful Tactical Initiatives Do Not Have
Great Success The ED Perspective

• Ease of Success Implementation
• Charge Nurse runs the ED A D
• Team Based Care A- D
• Inpatient Admission Ownership B D-
• Scribes B C
• Fast Track B C
• Physician Compensation System B- D
• Match Capacity to Demand B- D
• Bedside Registration B- D
• Observation Unit C- D

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Tactical Initiatives That Require Evaluation

• ED Mini Lab
• Dedicated Lab Phlebotomist
• Dedicated Radiology Technician
• Patient Tracking Systems
• Additional Staff
• Additional Space

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Problems with Traditional Approach to ED
Overcrowding

• Most ED efforts traditionally focus on tactical
  initiatives that ED has traditionally
  acknowledged control over
• No single tactical initiative appears to create
  significant ED LOS improvement on its own
• Success in reducing ED LOS or ambulance diversion
  appears to be related to multiple, simultaneous
  initiatives that focus on defined backup systems
  for common processes

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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Is the ED the Actual Problem?
ED crowding is actually one of several symptoms
of hospital inpatient capacity issues.

• ED Overcrowding
• Direct Admission Process
• Critical Care Intake and Transfer to Floor
• PACU Transfer to Floor
• Surgery Scheduling

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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Why Is It Hard to Fix theInpatient Admission
Process? The Bad News

• Inpatient admissions are inexorably linked to
  both
• Inpatient discharge process
• Movement of patients from floor to floor
• No clear ownership of any of these sub-processes
• No clear organized operations knowledge base to
  start from

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Tactical Initiatives for Hospital Admission

• Ease of Efficacy Implementation
• Roles Responsibility
• Hospital Change Nurse A C-
• Unit Charge Nurse A C-
• 3 Bed Ahead System A C
• Key Bed Process Automation A- B-
• High Census Bed Protocol B D
• Constrain Inpatient Bed Demand B- D
• Change of Shift Overrides C D
• EDMD Admit Privileges D D-
• Bed Control in ED D- B

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Key Opportunities to Increase Inpatient
CapacityMoving From Push to Pull

• Increase Inpatient Capacity
• Augment bed control/admission process
• Intake and Discharge Process Redesign
• Develop Metrics system to measure operational
  performance and provide feedback to staff and
  leadership for intake and discharge process
• Integration of IT for key processes

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Increase Capacity of Inpatient Bedsby
Constraining Demand

• Create dedicated outpatient area for short-stay
  patients and outpatient procedures, rather than
  utilizing inpatient beds
• Discharge patients earlier in the day in a more
  consistent fashion to decrease discharge/
  admission mismatch

• Formal multidisciplinary rounds to evaluate any
  patient in hospital greater than 15 days.

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Aligning Bed Identification Process - Moving
from Push to Pull System

• Formalize hospital ownership of all intake/
• discharge activities
• Hospital Administrative Supervisor
• Formalize unit responsibility for pre-planning
  bed ahead system
• Automation of key processes
• Bed request/notification system
• Hospital bed activity status with
  intake/discharge activity, KPIs, and staffing
• Capacity simulation modeling to predict
  bed/staffing needs using information from
  intake/discharge data to predict bottlenecks

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Communication Systems Real Time Notification of
Work Effort and Capacity

• Bed Tracking implement a bed tracking system
  that allows bed availability status to be
  monitored by Bed Control and Charge Nurse with
  the following notification capabilities
• Pending/actual
• Discharge cleans
• Open beds
• Pending discharge/transfer activity
• Occupied beds
• Staffing
• Key performance indicator

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Aligning Bed Identification Process - Moving
from Push to Pull System

• Obtain ETA on new patients
• Monitor time to arrival with Bed Control
  notification if receiving unit observes delay
• Develop bed cancellation policies
• Formal inpatient diversion notification system
• Bed control meeting with hard wired action plan
• Pre-plan critical care and step-down transfers to
  floor and telemetry removals 12 hours prior to
  transfer
• Formalize high census protocol with defined
  electronic hospital and medical staff
  notification of desired work effort

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Align Intake Process-Moving from Push to
Pull System

• Bed Control gives bed assignment and ETA to
  receiving unit
• Sending unit gives ETA with report
• Formal pre-planning prior to patient arrival
• Formal greeting, order placement and order
  initiation
• Formal monitoring and communication of new
  workload

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Aligning Discharge Process-Moving from Push to
Pull System

• Formal assignment of discharge process ownership
  for all patients
• Formal pre-planning 2 days prior to discharge of
  key nurse and care coordinator discharge
  activities
• Formalize evening pre-planning of discharge
  review
• Formalize time of discharge for patients and
  pre-plan for estimated time of discharge
• Formalize patient/family communication about
  method and time of discharge

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Aligning Ancillary Service Process

• Adjust housekeeping hours to match discharge
  demand
• Formal pre-planning of discharge activities with
  Charge Nurse for each shift
• Preplan at least 50 of transportation needs
• Prioritize category of potential discharge for
  lab and radiology

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Aligning Medical Staff Work Process

• Constrain Demand
• Utilize alternative hospital source for short
  stay/outpatient procedures
• Discharge patients earlier in the day in a
  maximum consistency fashion to decrease
  discharge/admission mismatch
• Intake
• Utilize primary contact for all incoming patients
  to either Admitting or to ED
• Time/date orders legibly
• Provide ETA on new patients
• Orders accompany patient prior to arrival on floor

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Aligning Medical Staff - Discharge Process

• Standardize predischarge planning procedures and
  tools
• Pre-plan discharges 2 days out
• Formal communication on evening prior to
  discharge
• Use of potential discharge category for
  lab/radiology tests needs by 0730
• Round by 0745 on potential discharges
• Lab/radiology test results on chart
• Review potential discharges as first step of
  morning rounds
• Initiate timed discharge orders prior to 0900
  with conditional orders

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Overview of Presentation

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change

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How to Organize a Plan to Decrease Length of Stay

• No magic bullet.
• Focus on key multiple key sub-processes.
• Develop organized plan which includes
• Resources to perform analysis, recommend changes
  and then implement changes
• Communication plan
• Assessment methodology
• Measurement system

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Key Reference Diffusion of Innovations, Everett
Rogers (1962, 1983, 1995)
Diffusion the process by which an innovation is
communicated through certain channels over time,
among the members of a social system. Includes
both spontaneous and planned spread.Innovation
an idea, practice, or object that is perceived
as new by an individual or other unit of adoption.
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Hospital Clones Diffusion Process
Phase Activity Target Communication Strategies
Rapid Cycle Testing Testing Early Adopters One-to-One Watching Tests
Mentoring Testing and Implementation Early Majority One-to-Several Promotion and Visibility
Next Grouping Mentoring Implementation and Spread Early/Late Majority Traditionalists Many-to-Many
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The Diffusion Curve
tipping point
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The Tipping Point

• The name given to that one dramatic moment in an
  epidemic when everything can change all at once.
  - M. Gladwell
• The part of the diffusion curve from about 10
  percent to 20 percent adoption is the heart of
  the diffusion process. After that point, it is
  often impossible to stop the further diffusion of
  a new idea, even if one wished to do so. - E.
  Rogers

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Adopter Categorization Speed of Adoption
Late Majority
Early Majority
Early Adopters
PAT Members Mentors
Resistors (Traditionalists)
2
13
35
15
35
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Successful Spread How to Manage It
Variables affecting the rate of adoption

• Attributes of the change
• Type of decision
• Communication channels
• The social system
• Promotional efforts
• Change attributes that affect adoption
• Relative advantage (evidence from testing)
• Compatibility with current system (structure,
  values, practices)
• Simplicity of the change and transition
• Testability of the change
• Ability to observe the change and its impact

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Lessons Learned

• Organization leadership needs to initiate and
  lead the change process to achieve dramatic
  results
• ED has capability to decrease LOS by 30 to 40
• Inpatient cycle times can decrease up to 70,
  which can reliably increase bed capacity by 10
• Customer satisfaction can predictably achieve
  90th percentile performance
• The ED can be defined as a significant revenue
  driver for the hospital

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Hospital Capacity Change Initiatives Critical to
Organizational Success A Noble Fight Lies
Ahead.
It is not the critic who counts, not the man
who points out the strong man stumbled or where
the doer of deeds could have done better. The
credit belongs to the man who is actually in the
arena whose face is marred by dust and blood
who strives valiantly who errs and comes up
short again and again who knows the great
devotions and spends himself in a worthy cause
who, at the best, knows in the end the triumph
of high achievement and who, at the worst, if he
fails, at least fails while daring greatly so
that his place shall never be with the timid
souls who know neither victory nor defeat.
- Theodore Roosevelt
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Opportunity for Discussion

• Scope of the Problem
• Traditional Approach to ED Crowding
• Key Concepts in Capacity Redesign
• Tactical ED Capacity Solution
• Relationship of ED Overcrowding to Inpatient
  Capacity
• Tactical Inpatient Capacity Solution
• Healthcare Change How to Design Change