Six Sigma To Optimize Patient Flow

Six SigmaTo

Optimize Patient Flow

Berger Health System

Sister Monica Justinger, C.S.A

Executive Director, Six SigmaBerger Health System or Circleville Ohio


Background Information

Pickaway Health Services Laurelville

Future Site of Berger Hospital North

Pickaway Health Services - Ashville

Berger Health Center Circleville - Wellness

Berger Health System Finance Department

Pickaway Health Services Circleville Family Practice

The Clyde I. Deffenbaugh Occupational Health Center

Pickaway Health Services Circleville OB/GYN

Pickaway Health Services Administration - Circleville

Pickaway Health Services Commercial Point

Future Site Southern Point Ambulatory Care Center

Berger Hospital – Circleville

Pickaway Health Services Circleville Internal Medicine




Annual Statistics 2001 2004

Total Admissions 1,754 3,290

Newborn Admission 329 403

Emergency Dept Visits 27,122 27,374

Surgical Procedures 2,796 4,926

X-Ray Procedures 44,439 55,691

Laboratory Procedures 371,372 502,570

Employees 345 700

Gross Revenue $51 Million $117 Million


Project Originated From A Parking Lot Issue:

MPHS Matched Only 83%

Med-Surg Staff Not Knowing Who to Call for IMPHS


Admitting Physician ?

PHS On Call Physician as attending vs PHS Physician seeing own patient.

30% of PHS IM Physician is patient’s PCP

WHO does the nurse call?


IMPHS PHYSICIAN MATCH INPATIENT RECORD

Diagnosis: ______________________________________________________________________________ Check if admitted by

Admitting Physician (who gives admission orders) ________________________________ PHS On Call Physician

Attending Physician (only if different from Admitting) ____________________________________________

Primary Care /Family Physician: ____________________________________________________________

Nursing Home Patient YES or NO (circle)Physician who sent/seeing patient at time of transfer___________________________________REMINDER: CHEST PAINS, CHF, AND ASTHMA PATIENTS PLACEMENT STATUS SHOULD ALMOST ALWAYS BE OBSERVATION. Please prompt the Ordering Physician’s for CORRECT STATUS FOR PLACEMENT. Additional diagnosis’s that meet OBSERVATION CRITERIA are abdominal pain, N/V, dehydration, syncope, HA, TIA, fever, gastroenteritis, dizziness, HTN, overdose, and seizures.90005060 Rev 02/2006

Patient Sticker

Room # _______________

Inpatient AdmissionObservation Outpatient Surgery Other_________________



VALIDATION LED TO OUR NEXT PROJECT

OPTIMIZING PATIENT FLOW BY BUILDING ON THE CONTINUAL OF

CARE OF THE HISTORY & PHYSICIAL


OpportunityOpportunityAn opportunity exist to improve the flow of inpatient information for use by the attending physician. The History & Physical is a key in the treatment of the patient. It is the documentation that begins the Plan of Care, therefore a foundation block that start the process of providing care based on a diagnosis. The admitting information not only provides medical information but also who is involved with the care and who provides post admission care.


• How can we be more customer focus so we are not asking the same medical questions over and over

• What are the road-blocks to get H & P information back to the physician in timely fashion. What is the “ideal” turn-around time?

• What are the repeat and rework steps we do.

Questions


• 76% of PHSIM admission are from 7:00pm to 7:00am

• 79% of H & P done by House Officer or NP

• 50% Transcribed between 12:00noon to 4:00p and 26% after

4:00pm, 0% before 8:00am

• Average turnaround time for H & P to be placed on Chart was

over 18 hrs.

• Less than 50% of the time was the ED H&P Notes on the Inpatient Chart within 120 minutes

Information

ED RN Assessment

ED Physician Assessment

(Notes)

ED Triage RN

Flow of Obtaining IN-PATIENT Information

RN Admission Assessment

CNP does H/P

Add to info/TX

ADM Rounds per MD

House Officer does H/P

YES

NO Admit or Attending

Dr. does H/PNO

NO Info on PatientED Notes

H/P

?/Assess

Patient’s PCP(Knows Patient)

YESYES


Admission Times 7/18/05 through 8/5/05

0:00

2:24

4:48

7:12

9:36

12:00

14:24

16:48

19:12

21:36

0:00

7/167/17

7/187/19

7/207/21

7/227/23

7/247/25

7/267/27

7/287/29

7/307/31 8/1 8/2 8/3 8/4 8/5 8/6

Admission Date

Ad

mis

sio

n T

ime

ED Notes H/P

Chief Complaint Chief ComplaintHistory of Present Illness History of Present IllnessPast Medical/ Surgical HX Past Medical/ Surgical HXAllergies MedicationsMedications AllergiesSocial History Social HistoryFamily History Family HistoryReview of Systems Review of SystemsPhysical Exam Physical ExamPrimary Care Doctor General AppearanceLab Data Vital SignsAdditional Data HEENTER Course NeckProcedures LungsCritical Care CardiacConsults AbdomenMedical Decision Making ExtremetiesImpression NeuroPlan X-ray and Lab DataPrimary Care Doctor Impression/ Plan

Tools

Inpatient ED Dictation to Transcription

0

5

10

15

20

25

30

35

>60 Min <60 Min

Target

Nu

mb

er 2300-0700 Total

0700-1700 Total

1700-2300 Total


52.8 Ed Dictation on Line 6 (60 minute line)

Admission Times 7/18/05 through 8/5/05

0:00

2:24

4:48

7:12

9:36

12:00

14:24

16:48

19:12

21:36

0:00

7/167/17

7/187/19

7/207/21

7/227/23

7/247/25

7/267/27

7/287/29

7/307/31 8/1 8/2 8/3 8/4 8/5 8/6

Admission Date

Ad

mis

sio

n T

ime

•50% Transcribed between 12:00noon to 4:00p and 26% after

4:00pm, 0% before 8:00am

72% in two weeks

89% in six weeks


ED ( Inpatient) Dictation to Transcription Turnaround Time

Inpatient ED Dictation to Transcription

0

5

10

15

20

25

30

35

>60 Min <60 Min

Target

Nu

mb

er 2300-0700 Total

0700-1700 Total

1700-2300 Total

Inpatient Dictation to Transcription Time

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

-1 2 5 8 11 14 17 21 24 27 32 35 41 46 51 59 65 72 81 91 101

110

121

129

165

280

Minutes

Occ

urre

nce

n=103

LSL=0

USL=198

Mean=55

Median=37

Mode=24


Inpatient Dictation to Transcription Time

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

-1 2 5 8 11 14 17 21 24 27 32 35 41 46 51 59 65 72 81 91 101

110

121

129

165

280

Minutes

Occ

urre

nce

n=103

LSL=0

USL=198

Mean=55

Median=37

Mode=24


Total Minutes to Transcripton Completion

0

50

100

150

200

250

3000:

06

0:43

0:55

2:29

4:12

5:32

6:27

7:38

7:49

8:04

8:31

9:41

10:0

4

11:3

0

11:4

2

12:1

8

13:3

4

14:2

4

14:4

1

15:1

7

15:5

4

16:3

1

16:3

9

16:4

5

17:2

5

18:0

1

18:2

4

19:4

6

20:1

8

20:5

4

21:4

8

22:1

2

22:4

2

23:1

3

23:5

8

Time of Day

Min

ute

s


ED Notes H/P

Chief Complaint Chief ComplaintHistory of Present Illness History of Present IllnessPast Medical/ Surgical HX Past Medical/ Surgical HXAllergies MedicationsMedications AllergiesSocial History Social HistoryFamily History Family HistoryReview of Systems Review of SystemsPhysical Exam Physical ExamPrimary Care Doctor General AppearanceLab Data Vital SignsAdditional Data HEENTER Course NeckProcedures LungsCritical Care CardiacConsults AbdomenMedical Decision Making ExtremetiesImpression NeuroPlan X-ray and Lab DataPrimary Care Doctor Impression/ Plan

BUILDING ON THE CONTINUAL OF CARE OF THE HISTORY & PHYSICIAL


BERGER HOSPITAL

600 North Pickaway Street Circleville, Ohio 43113

HISTORY AND PHYSICAL

Patient: Unit#: Acct#: Date: Room#:

Primary Care Physician: Attending Physician:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL / SURGICAL HISTORY:

MEDICATIONS: ALLERGIES:

SOCIAL HISTORY:

FAMILY HISTORY:

REVIEW OF SYSTEMS:

PHYSICAL EXAM:

GENERAL APPEARANCE:

VITAL SIGNS:

HEENT:

NECK:

CHEST:

LUNGS:

CARDIAC:

ABDOMEN:

G/U:

RECTAL:

BACK:

EXTREMITIES:

SKIN:

PULSES:

NEURO:

X-RAY AND LAB DATA:

IMPRESSION:

PLAN:

BERGER HOSPITAL

600 North Pickaway Street Circleville, Ohio 43113

HISTORY AND PHYSICAL

Patient: Unit#: Acct#: Date: Room#:

Primary Care Physician: Attending Physician:

Upon review of the patients ER H&P and making my own assessment, I am in agreement with the present H&P to include:

*Chief Complaint *History of Present Illness *Past Medical and Surgical History *Social History *Review of Systems During my evaluation I found the following to be exceptions to the ER H&P: IMPRESSION:

PLAN


The Rewards

ED Inpatient Admission H&P

Transcribed < 60 minutes

Emergency Department Using

Correct Dictation Line “What’s Next”

Supports Continuity of

Care

Physician Ownership

Building on Clinical

Information vs Duplication

Inpatient Record Transcription Time Decreased Average

15min/chart

Registration Supports Patient

Care

“PHS IM”


Six Sigma, paving the way for BHS to become “The Best Six Sigma, paving the way for BHS to become “The Best Community Hospital & Healthcare System in Ohio” one project Community Hospital & Healthcare System in Ohio” one project at a time.at a time.


Six Sigma To Optimize Patient Flow

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