October 23, 2012 1 It takes a Team A multidisciplinary approach to managing hospital entry points Presented by: Maria Antonucci, MS, RN and Susan F. Byrd, RN, BSN, CEN
Mar 26, 2015
October 23, 2012
1
It takes a Team
A multidisciplinary approach to managing hospital entry points
Presented by: Maria Antonucci, MS, RN and Susan F. Byrd, RN, BSN, CEN
1926 - American Legion Hospital for Crippled Children
All Children’s Oct. 1, 1967
All Children’s Hospital History
All Children’s HospitalOpened Jan. 9, 2010
April 4, 2011: ACH integrated with Johns Hopkins Medicine 2
• 738,000 Square Feet• 259 Inpatient Beds• 97 Bed NICU
- 35 Bed Level II- 62 Bed Level III
• ACH Heart Center- 22 Bed CVICU- 2 Cardiac Operating Rooms- 3 Cath Labs- Interventional Radiology Suite
• 28 Bed PICU• Vincent Lecavalier Pediatric Cancer and Blood
Disorder Center- 28 Bed Unit: BMT, Positive Pressure
Floor• 12 Operating Rooms & Special Procedures Unit• Outpatient Care Center (OCC): 250,000 sq ft:
physician offices, diagnostic services, laboratory, Ronald McDonald House, Conference Center, administrative offices
All Children’s HospitalOpened Jan. 9, 2010
All Children’s Hospital
3
8,830
73,127
3,345
200
8.0
2.02
Inpatient 2,771
Outpatient 6,482
Cardiac Closed 202
Cardiac Open 226
Cardiac Transplant 4
Cardiac Cath 397
42,080
142,684
137,370Outpatient Visits - Outreach
Surgeries
Average Length of Stay
Case Mix Index (APRDRG)
Admissions
Patient Days
Observation Patients
Average Daily Census
Emergency Center Visits
Outpatient Visits - CampusSource: ACHS Operating Indicators Report
All Children’s HospitalFY2012 Statistics
4
All Children’s HospitalTop 10 Specialties by DischargeFY2012
5
Attend Specialty Cases% Total Cases
Days% Total
Days
PEDIATRIC MEDICINE* 3,144 35.7% 11,960 16.8%NEONATOLOGY* 1,133 12.9% 29,330 41.3%HEMATOLOGY / ONCOLOGY* 1,018 11.5% 7,566 10.7%CRITICAL CARE 609 6.9% 5,957 8.4%PEDIATRIC SURGERY* 571 6.5% 1,970 2.8%GI / NUTRITION 524 5.9% 2,551 3.6%NEUROSURGERY* 429 4.9% 1,797 2.5%PULMONOLOGY 263 3.0% 1,921 2.7%ORTHOPAEDICS 253 2.9% 930 1.3%CARDIOVASCULAR SURGERY* 221 2.5% 3,699 5.2%
Cumulative for Top 10 8,165 92.6% 67,681 95.3%
*Employed physicians
100 Day Workout Methodology
• Supports focus on Pursuing Perfection goals to improve Service, Outcome and Cost
• Action-oriented change model: Rapid-Cycle Testing (RCT)
• Utilizes Lean Six Sigma principles with Just-In-Time (JIT) training
• Brings together teams of managers, frontline staff and physicians
• Improvement ideas and actions plans from teams
• Establishes accountability– Kickoff, 30-60-90 day check-ins, Summation– tool for tracking change ideas and results
What is Lean Six Sigma?
– A combination of two process improvement methodologies:
– Lean involves removing wastes from a process
– Six Sigma involves reducing variation in a process
Patient Flow Workout
• Right patient, right bed, right time
• 60 minutes or less% EC to Appropriate Bed
84.8380.94
65.85
85.4986.77
49.57
56.0358.64
53.54
43.65
73.1171.10 68.08
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Aug-11
Sep Oct Nov Dec Jan Feb Mar Apr May June July Aug-12
Pe
rce
nt
GOAL = 80%
Hospitalist as Gate Keeper
Strategies for Improving Inpatient and Observation Bed Utilization for
Patients Admitted Through the EC
Goals
• Improve utilization of inpatient beds• Decrease the % of reclassified patients to
less than 10%• Improved utilization of CDU beds• Improve patient placement on all referrals to
hospitalist service• Improve collaboration between hospitalists
and EC physicians in the ongoing care of patients not ready for discharge from the EC
Rapid Cycle Test
• Routed direct admits with reduced length of stay to EC
• Had Hospitalist determine next level of care– Clinical Decision Unit– Observation– Inpatient
RCT Outcome
Hospital Observation Census
0.0
5.0
10.0
15.0
20.0
25.0
1 2 3 4 RCTStart
6 7 8 RCTEnd
Week
Ave
rag
e D
aily
Cen
sus
Hospital Inpatient Census
150.0160.0170.0180.0190.0200.0210.0220.0
1 2 3 4 RCTStart
6 7 8 RCTEnd
Week
Aver
ag
e D
ail
y C
ensu
sRCT Outcome
Emergency Center Census
0.020.040.060.080.0
100.0120.0140.0160.0
1 2 3 4 RCTStart
6 7 8 RCTEnd
Week
Ave
rag
e D
aily
Cen
sus
RCT Outcome
0
20
40
60
80
100
120
140
160
180
200
Time in EC Door to Doctor Doc. To Disp.
Pre
Post
RCT Outcome
RCT Outcome
Pre Post Percent dif.Goals1. Decrease the number of observation patients placed in an inpatient unit 105 107 1.9%2. Increase CDU volumes 117 105 -10.3%3. Decrease the volume of Case Management status conversions 0.24 0.17 -29.2%4. Decrease average time in the Emergency Center 172.8 169.3 -2.0%5. Decrease the door to doctor time for the Emergency Center 57.3 55.6 -3.0%6. Decrease the doctor to disposition time for the Emergency Center 99 96.7 -2.3%
What we learned…
• Slight decrease in patient categorized as observation
• No real change in Emergency Center time in department indicators
• Less rework for case management correcting patient status
• Difficulty with Hospitalists’ staffing
CM patient flow workout
• Correct assignment of patient type on admission– Noticed a large number of emails to change status– Most were inpt to obs– Drilled down the obs status– Only 2 status available– Decision to collaborate with teams– Multiple access points identified
Would Case Management in the EC be a better gate keeper?
Would it help meet the needs identified in the CM patient flow workout?
Back to the drawing board…
Assumptions
• If patients have correct assignment of status upon admission:– Right patient in right bed– Increased utilization of CDU– Decrease rework for status change/lean
process
Access case management
Role includes all the functions of the current hospital case managers with the focus being on patients at the point of entry into the hospital.
Hospital entry points
• Emergency Center
• Direct Admits
• Transfers
• Same day surgery
How do we get there?
ROI for EC Case manager
What can they do?
An Access Case Manger can prevent inappropriate admissions, improve discharge planning, decrease cost and enhance patient satisfaction. They can decrease utilization of the EC for non-emergent visits, promote the use of community resources and improve discharge planning to avoid excessive costs.
EC CM staffing plan
• Success = staffing• 7 day/week, 12-hour/day (1100-2300hr) • Salary range average is $34/hr. • 2.1 FTE’s = $148,512 + benefits
Revenue Opportunity
• The LOS = 5 days for non ICU. • Medicaid reimbursement is $2765.69. • One inappropriate admission would cost $8295. • One/week/year would cost $431,340.• Potential to avoid one inappropriate admission
per week = $431,340• 2.1 FTE case manager salaries per year
= $148,512
• Net revenue = $282,828
Opportunity for increase in patient satisfaction, staff satisfaction, quality of care patient flow, bed turnover…
PRICELESS!!!
Goals of position:
The access case manager will be based in the EC working with the multidisciplinary staff in developing a plan of care for the patients. They will be a resource in the decision making process care as it pertains to possible admission.
Other functions
• Facilitate patient flow to correct bed
• Facilitate and expedite testing
• Implement EC discharge planning
• Follow up phone calls
• Patient rounds
Where are we today
• Have 2 positions filled
• Learning to navigate through the EC
• Learning First Net
• Identifying process
• Full roll out planned
Next steps
• Tackle direct admissions
• Entire patient placement center collaboration
Questions ?
• Thank you for listening!