Patient Safety Summit
Throughput- Led Initiatives
with EPIC Source Data
January 8, 2014
Judy Shepard, RN, MN
Director, Quality/ Bed Management
Raymond Smith, MBA
Director, Clinical Decision Support
1
Conflict of Interest Disclosure
Raymond Smith, MBA
Judy Shepard, RN, MN
Has no real or apparent conflicts of interest to report.
2
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.
3
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
4
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.
5
Current ECC
6
"MD Order To Patient Placement" Timeline
July 2012 to October 2013
PROJECT KICK OFF
START
VALUE STREAM MAPPING
DETERMINED
TARGET GOAL MET
CURRENT
PROCESS FLOW
FINALIZED
17 Jul
17 Aug
17 Sep
17 Oct
17 Nov
17 Dec
17 Jan
17 Feb
17 Mar
17 Apr
17 May
MEASUREMENT OF
PROCESS FLOW
STEPS/ VARIATION
REVIEW
IMPLEMENTED
CHANGE
MANAGEMENT
GSU HIT
ENGAGEMENT
PROJECT
7
QI Perspective
Reminders
Policies,
Procedures,
& Processes
Audits &
Feedback
Safety
Culture
Knowledge
Sufficient
Staff
External
Environment
Clinical
Leadership
Acuity
Systematic
PI models
Behavior
Multidisciplinary
Teams
8
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
9
Global View of Patient Throughput
Intake
Inpatient Care
Disposition
Perioperative Services
• Improved OR prep for day of surgery
• Improved start of day activities
• Improved start and TAT
Case Mgmt
Diagnostic
• Prioritize discharges
• Coordinate with
• Develop case scheduling process
Nursing/Physicians
Testing
• Timely TAT
• Scheduled inpatient testing
• Long stay patient
placement
Bed
Management
Admissions
Emergency Department
• Initiation of rapid care protocols
• Streamlined triage processes
• Bed-side registration
Direct Admissions from
Clinics
• Screening for appropriateness
• Avoid direct admissions going
to the ED
• Anticipatory
planning for beds
• Coordination
with Case
Manager for
discharges
• Global view
of all beds
• Physician
champion to
facilitate
timely discharge
• Family communication
Environmental
Services
MD Coverage
• Timely discharge order
• Coordination with
Case
Manager/
Social Worker
Effective
Patient
Throughput
• Coordination with Bed
Mgmt and Nursing to match
demand
Day of Discharge
• Communication with
family
• Nursing/Case
Manager/Social Worker
support at the discharge
• Notification of dirty bed
• Timely bed turnaround
Guest Services
ICU/Step-down/
Telemetry
• Coordination with Nursing
and ED
• Facilitation of patient
transfers
• Placement of
Long Stay patients
Nursing Units
• Coordinate with Case Mgmt
• Point person for facilitation
External Facility Transfers
• Screening for appropriateness
• Requires financial clearance
of flow
• Initiation of bed cleaning
Information Systems
• ECIN
• Invision
Global View of Patient Throughput
2
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
10
Six Sigma DMAIC Methodology and CDS Tools
(fact based decision making)
Initiate, scope,
and plan the
project
Define
Understan
d the
current
process
Measure
Determine
and verify
root causes
of problems
Analyze
Develop
and test
improved
process
Improve
Implement
and
monitor
improved
process
Implement
Provide
support for
ongoing
management
of process
Control
Deliverables
Root Cause (s)
Team Charter
Baseline Data
Confirmed with
Data
SIPOC
Detailed
Workflow
Voice of the
Customer
Value Stream
Mapping
Cost- Benefit
Analysis
Implementation
Plan
Standard
Operating
Procedure
Pilot Results
Implemented
Process
Monitoring Plan
Kaizen Events
(Rapid Cycle
Activities)
Results
11
Discharge and Bed Transfer Requests per Hour
Discharge Orders
Transfer Orders
400
350
Avg # requests per hour
300
250
200
150
100
50
0
12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
12
Triage Level 5
Triage Level 4
Triage Level 3
ED Triage Level Volumes per Hour of Day
2012
Triage Level 2
700
Triage Level 1
Average patients per Month
600
500
400
300
200
100
0
12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
13
Grady Memorial Hospital
Emergency Department
Triage Level 1- Chief Complaints
Grady Memorial Hospital
Emergency Department
Triage Level 2- Chief Complaints
Avg. 5 patients
Per hour
MVC
Chest Pain
23.1%
Suicidal Ideations
23.1%
36.1%
GSW
29.5%
Cerebrovascular Acc
SOB
16.4%
19.1%
AMS
6.6%
MVC
17.5%
Resp Distress
6.6%
Psych Eval
17.3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
0%
Avg. 187 patients
Grady Memorial Hospital
Per hour
Emergency Department
Triage Level 3- Chief Complaints
Abd Pain
5%
10%
15%
20%
25%
30%
35%
Avg. 86 patients
Per hour
17.0%
15.0%
Abscess
15.0%
40%
25%
21.9%
Knee Pain
11.0%
0%
20%
31.0%
Leg Pain
12.3%
Headache
15%
Dental Pain
16.6%
MVC
10%
Back Pain
25.5%
SOB
5%
Grady Memorial Hospital
Emergency Department
Triage Level 4- Chief Complaints
34.6%
Chest Pain
0%
Grady Memorial Hospital
Emergency Department
Triage Level 5- Chief Complaints
Med Refill
5%
10%
15%
20%
25%
30%
35%
Avg. 21 patients
Per hour
33.1%
Dental Pain
23.9%
Back Pain
19.0%
Rash
14.1%
MVC
9.8%
0%
14
Avg. 70 patients
Per hour
10%
20%
30%
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
40%
20,649 cases
reviewed
Avg. Bed Request to Assign Turnaround Statistics for ED
150
2000
1800
120
1600
1400
1200
2012 National Benchmark (74 min.)
1000
60
800
600
30
400
200
0
Avg Request to Assign
2012 National Benchmark
Total Patients
0
Jan2012
38.7
Feb2012
32.9
Mar2012
47.5
Apr2012
51.2
May2012
32.5
Jun2012
36.5
Jul2012
46.5
Aug2012
66.5
Sep2012
74
Oct2012
100
Nov2012
116
Dec2012
121
Jan2013
115
Feb2013
126
Mar2013
72
Apr2013
63
May2013
56
Total Requests
Avg # Minutes
90
Jun2013
92
74
74
74
74
74
74
74
74
74
74
74
74
74
74
74
74
74
74
1749
1408
1669
1808
1487
1733
1655
1785
1829
1765
1900
1770
1888
1721
1835
1661
1763
1735
Avg. Bed Request to Assign Turnaround Statistics for ED
By Bed Type
300
Source: EPIC ADT Workbench Report
# Avg Minutes per Month
250
200
150
Step Down
100
50
0
15
Med/ Surg
ICUs
Bed Request/ Physician Order to Patient Placed in Bed Workflow Process
2
1
Bed request
is received
from ED
physician
A
3
MD determines
status
(inpatient/
observation)
admit order
from ECC B
ECC
Resident/
Attending
notifies
admit team
4
Admit team writes/
signs admission
order
C
5
Bed Management
notified within EPIC
work queue
InterQual process
review is completed
pending request
information is
accurate
E
F
D
6
Is InterQual
criteria met?
G
Study Period #2- From A to B (avg 9.1 min)
Study Period #3- From A to B (avg 1 min)
From B to C (avg 64.3 min)
From B to C (avg 67 min)
From B to C (avg 56 min)
From C to D (avg 103.3 min)
From C to D (avg 11 min)
From D to E (avg 19 min)
From C to D (avg 127 min)
Admissions Intake
RN contacts MD or
ED case manager,
admitting team
From D to E (avg 16.8 min)
From E to F (avg 29.7 min)
From D to E (avg 15.3 min)
Issue
discussed
8
ECC Clerk calls
Transport Services
or places transport
order in
TeleTracking
ECC RN notifies
ECC Clerk to
contact
Transport
Services
ECC RN
calls
report
Does ECC RN have
to transport
patient?
No
Yes
Is Floor RN
Available to
Receive
Report?
J
Is clean bed
available?
No
EVS customer
support is contacted
for escalated priority
assignment
No
Study Period #1- From A to B (avg 10.3 min)
Yes
Patient on
Hold
In ECC
Yes
Admissions intake
RN requests new
order (hard copy
or electronic)
7
ECC RN sees bed
assignment in Epic
I
Admissions bed
planner looks on the
Stat Admit board for
available bed type
H
K
10
TeleTracking
assigns
transporter
If available
Yes
9
RN/Provider will
transport patient w/
monitor
No
Fax report viewed or
report given at
bedside
11
Transporter
arrives to floor/
unit and patient is
transported to
assigned bed
Patient is placed in
assigned bed
Transport delivers
admitted patient to
assigned unit
L
Study Period #1- From H to I (avg 179 min)
From J to L (avg 20 min)
Study Period #2- From H to I (avg 69.6 min)
From J to L (avg 29.7 min)
Study Period #3- From H to I (avg 167 min)
From J to L (avg 43 min)
Study period #1- 393.7 min (6.6 hrs) with 20 pts reviewed
Study period #2- 235.1 min (3.9 hrs) with 13 pts reviewed
Study period #3- 409.3 min (6.8 hrs) with 10 pts reviewed
16
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
Focus of Lean: Elimination of Waste
17
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
18
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
19
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
20
Parking Lot Issue(s)
1
·
·
·
·
·
·
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
2
·
·
·
Delay in seeing patient
Inappropriate admission
Lack of required information
3
·
·
·
·
·
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
·
·
·
·
·
·
·
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
7
·
·
·
·
·
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
8
·
There is delay in seeing bed available in EPIC
·
·
·
·
·
·
·
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
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
·
·
Delay in transport arriving, knowledge of wait time, priority for transport
Patient not appropriate acuity
6
9
10
11
21
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
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
22
Quality/ Performance Improvement
2013 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.
23
Bed Management Model
RN Bed Czar
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
ED
PACU, Cath Lab, other procedure areas
ED CM performs clinical review for
appropriateness of admission. Unit
Secretary notifies Admissions of bed
need.
Each area notifies Admissions of bed need
via system ~ 1 hr. prior to bed needed
Charge Nurse calls back within 10
minutes with final clean bed
assignment on the unit.
Admissions
Patient Access
Admissions CM performs
clinical review for
appropriateness of
admission
Financial screening
performed by PAR
Pages charge RN/designee w/ bed assignment.
PACU, Cath Lab, other procedure areas
ED
Physician/designee calls admissions CM with
patient clinical information and discusses plan of
care
Admissions CM
Charge RN or Unit Designee
Admissions evaluates bed board and
places patient in appropriate bed.
Admissions notifies Charge RN of
admission.
Direct admissions from clinics and
transfers from other hospitals
Direct admissions from clinics and
transfers from other hospitals
Report automated/faxed. Receipt of report verified
and questions answered. Patient transferred w/i
30 min
9
Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia
25
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
26
Thank You
Questions???
27