RWJ URGENT Matters

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• RWJ / URGENT Matters
• Inova Patient Flow Redesign Case Study
• 9/23/04

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Inova Health System - 5 Hospital System Not for
Profit
Inova Fairfax Hospital/Inova Fairfax Hospital for
Children

• Opened in 1961 with 165 beds
• 656-bed regional tertiary medical center
• 156 additional beds approved as part of Inova
  Heart Institute (opening 2004)
• 50,858 adult admissions
• 71,675 emergency visits
• 10,885 births
• Inova Emergency Care Center/ Reston
• Inova HealthPlex

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Northern Virginia Population Growth 2000 to 2020
Inner Suburbs
Outer Suburbs

• 19 growth through 2020
• (1 a year) 250,000 more people

• 77 growth through 2020
• (3.4 a year) 400,000 more people

912,000
738,000
514,000
Source Metropolitan Washington Council of
Governments
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Goal Improve patient throughput

• Current State Findings
• 78 of boarder patients are waiting 1 - 4 hours
  until they are placed in their assigned room
• Avg. daily ED admissions 51
• 93 of patients are discharged after 11 AM
• Units believed that room turnover was an issue
  in delays

Avg. 1,300 patient boarders per month
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Recognizing the Need for a House-wide effort
Throughput Champion Builds Coalition
AVP, COO Inova Heart Hospital
CEO / Admin. Council
Hospital Management Team

• Observing continued frustration of directors
• No accountability for Boarder patients Push vs.
  Pull
• Concerned by data and trends
• Feels that ED throughput cannot be solved in
  isolation

Clinical Chairs
Source Healthcare Advisory Board
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Critical Success Factors for our Re-design Session
2. Pull vs. Push
1. Honor Past Work
4. Partnering with physicians and customers
(patients / family)
3. Think creatively to identify a few high
impact items
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More Than an ED Problem Mapping the Whole
System

• Operations Leaders
• Nurse Executives
• Information Systems
• Floor RNs
• Floor PCDs
• Physicians
• ED Leadership
• ED RNs

• Case Management
• Transport
• Registration
• Lab / Rad leadership
• Quality
• Housekeeping

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Process impact on key indicators

• Selected processes to improve that would add the
  most value.
• Process Boarders Re-Route Hours
  Customer Service Patient
  Throughput
• Patient Discharge X X
  X
  X
• ED Throughput X
  X X
  X
• Bed Turnaround Time X
  X X
  X
• Internal Patient Transfer X
  X X
  X
• 
  

8
0
5
9
Bed Turnaround Time - Many opportunities for
delays.
Required Communication
Delay 1 Reporting of discharge
Patient Discharged
Housekeeping Notified
Delay 2 Slow bed turnover
Dirty Bed
Delay 4 Slow reporting of bed placement
location to unit or ED
Bed Cleaned
Delay 3 Slow reporting of clean bed
Bed Control Notified
Patient Assigned Bed
Source Healthcare Advisory Board
10
Bed Turnover - Implemented the Housekeeping
Request System (HRS) to improve and track bed
turnaround times
Housekeeper responds within established parameters
No
HRS pages closest available housekeeper
EVS Manager is notified via HRS and sends staff
to clean room
Bed needs cleaning
Unit Secretary or Designee is notified
Unit Secretary or Designee enters info in HRS
Start
Yes
Yes
Housekeeper notifies HRS that he/she is starting
to clean room
Patient room/bed is ready for Occupancy
HRS Notifies registration Discharge Complete
No
Housekeeper cleans the room within established
parameters and notifies HRS
End
EVS Manager is notified via HRS paging system and
investigates. Corrects problem(s) and notifies
HRS when room is clean
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HRS - Average Room Turnaround Time - Outcomes
Teams goal is 30 minute Average Room Turnaround
49 min. decrease
HCAB benchmark for room turnaround is 45 min.
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Team Triage - (TT)

• Team Triage (TT) applies the concept of early
  intervention
• TT team is made up of a physician, RN, Tech,
  Scribe and Registrar
• TT, in conjunction with mini-registration,
  reduces the throughput of the TT triaged
  patients, as well as overall ED volume.

• A team of emergency care professionals
  specifically dedicated to the ED Triage area to
  initiate and expedite patient care close to the
  patient point of entry.

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Outcomes of Team Triage Pilot

• 34 of patients seen were "treated and streeted"
• Sign in to MD exam - decrease of 72 minutes
• Total ED throughput - discharged patients - 44
  minute decrease
• LWBS - pre-trail average 4.45 Team Triage pilot
  - 0.81

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Team Triage Satisfaction Survey - My Overall
Experience In Triage Area
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Team Triage Satisfaction Survey - Seeing A
Physician In Triage
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Team Triage Satisfaction Survey - I Would Return
To The ED For Care
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11 AM Discharge Campaign - Work in Progress
Inpatient Discharges by Time
Jan - 10 of patients discharged before 11
AM May - 13 of patients discharged before 11 AM
3000
2500
2000
Number of patients
Discharged
January
1500
1000
February
500
March
0
April
Key for Inova is to work with Physicians to round
earlier patients
May
1901-2100
0001-0700
0701-1100
1101-1500
1501-1900
2101-2400
Time of Day
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T8 11 AM Discharge Pilot - Some Units Yielding
Better Results
T8 Percentage of Patients Discharged Before 11
AM
38
40.00
35.00
30.00
21
25.00
20.00
12.50
10.60
15.00
8.60
8.40
10.00
5.00
0.06
0.00
Mon
Tues
Wed
Thurs
Jan '04
Dec '03
Nov '03
3/1
3/2
3/3
3/4
T8 Number of Patients Discharged Before 11 AM
6.00
5.00
5.00
4.00
3.00
3.00
2.00
1.38
2.00
1.09
1.10
1.00
1.00
0.00
Mon
Tues
Wed
Thurs
Jan '04
Dec '03
Nov '03
3/1
3/2
3/3
3/4
Daily
Daily
Daily
Avg.
Avg.
Avg.
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Implementation Team Overview Keys to Success
Candice Saunders Mary Dixon
Executive Steering Committee
Patient Discharge Team
ED Admission Team
Bed Turnaround / Internal Transfers Team
Effort led by and championed by senior executive
Holding ED Director and Operations Directors
accountable for outcomes
Communication, Communication, Communication!
Hold process teams accountable for work to be
accomplished
Pilot programs and measures pre and post data for
outcomes results
House-wide initiative involvement, not just one
departments issue