Transcript No Slide Title

The Ideal Patient
Experience and the
Importance of Improving
Patient Access
Maryland Association of Healthcare Executives
September 20th, 2005
Boston • Chicago • New York • San Francisco
Today’s Agenda
 Defining
the Ideal Patient Experience
 The
Case for the Ideal Patient
Experience
 Patient
Access and Achieving the Ideal
Patient Experience
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
“Most hospitals are islands of clinical
excellence surrounded by the DMV”
- Ian Morrison (Health Care Futurist)
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
The Ideal Patient
Experience is the
result of a provider
orienting its entire
organization and
processes to deliver
clinical excellence in
the context of an
optimal patient
encounter
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
Clinical Excellence
• Superior Patient
Outcomes Across the
Continuum
• Unparalleled Patient
Safety
• Integrated Teaching and
Clinical Care Platform
• Research that Spans the
Spectrum from Bench to
Bedside
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
Excellence in
Care Delivery
• Compassionate Family
Centered Care
• Coordinated Care in the
Optimal Setting Across the
Continuum for the Patient
and Family
• Easy Access and Seamless
Scheduling and Use of
Resources
• Effective Referring
Physician Education and
Service
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
Operational
Excellence
• Easy Patient and Family
Access to and Navigation of
the System
• Singular, Consistent
Generation of Patient,
Family, and Provider
Information
• Cost Effective Delivery of
Care and Services
• Ease for Physicians and
Personnel to Provide
Service
©2005 The Chartis Group
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What is the Ideal Patient Experience ?
The Ideal
Patient Experience
• Physicians
• Employees
©2005 The Chartis Group
• Patients
• Families
The Ideal Work
Experience
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Today’s Agenda
 Defining
the Ideal Patient Experience
 The
Case for the Ideal Patient
Experience
 Patient
Access and Achieving the Ideal
Patient Experience
©2005 The Chartis Group
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The Patient Perspective
Consumerism: Not just a concept anymore

2001 was the first year that over 50% of patients surveyed responded
that their hospital preference would supercede their physician’s
recommendation

In 2001, consumers ranked hospital reputation over physician
recommendation in terms of determining factors when choosing a
provider

Out-of-pocket costs to employees are growing – healthcare
premiums projected to increase 7% above wage increase index

Unconstrained healthcare knowledge access via the internet

Rise of the educated consumer who demands healthcare services
and choice

Studies have shown that patients who have a suboptimal experience
accessing services also are more prone to poor satisfaction scores
with their inpatient stay and are less likely to recommend the
provider
©2005 The Chartis Group
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Choice will be Driven by the Total Experience
The Patient Experience, The Physician
Experience and The Employee Experience
•
•
•
•
•
Ease of Use
Ease of Access
Quality of Care
Coordination of Care
Affordability
Charles Schwab meets Disney meets the Mayo Clinic
©2005 The Chartis Group
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The Case is Made
Success in the next five to ten years will go to the institution
that provides The Ideal Patient Experience
Consumers: Our patients and families demand it and will
choose because of it
Employees: The Ideal Patient Experience provides and relies
upon The Ideal Work Experience – necessary in
these labor markets
Physicians: Unparalleled ease, effectiveness and quality –
they channel patients
Payers:
©2005 The Chartis Group
It will be the institution of choice – a great source
of leverage
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Today’s Agenda
 Defining
the Ideal Patient Experience
 The
Case for the Ideal Patient
Experience
 Patient
Access and Achieving the Ideal
Patient Experience
©2005 The Chartis Group
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Core Patient Processes
Defining Quality –
From the Patient’s Perspective1
• Respect for Patient’s Values,
Preferences and Expressed Needs
• Coordination and Integration of
Care
• Information and Education
• Physical Comfort
• Emotional Support and Alleviation
of Fear and Anxiety
Top Processes which Drive
Patient Experience
• Patient Access and Flow
• Care Delivery
• Care Coordination
• Deliver Diagnostic Services
• Therapies, Intervention and
Support
• Workforce Recruitment, Retention
and Development
• Involvement of Family and Friends
• Transition and Continuity
• Access to Care
1
National Research Corporation / Picker Institute
©2005 The Chartis Group
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Core Patient Processes
The Ideal Patient Experience
Core Process Hierarchy
Patient Facing
Processes
Patient Support
Processes
Infrastructure
©2005 The Chartis Group
•Patient Access and Flow
•Care Coordination
•Care Delivery
•Communication and Education
•Dietary Services
•Revenue Cycle and Billing
•Environmental Services
•Facility Services
•Information Management
•Supply Chain Management
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Why Is Patient Access and Capacity Enhancement (PACE) Important?
Characteristics of Providers Who Invest in
Patient Access and Capacity Enhancement
•
Wide swings in average daily census (low on the weekends,
peaking Wednesday/Thursday).
•
Wide swings in hourly census
•
Operationally “full” facility, yet reporting 20% of beds as
unoccupied
•
Periodic capacity bottlenecks (ED, OR, ICU’s)
•
Seemingly endless game of “musical chairs” in an effort to find
capacity
•
Significant physician, staff and patient frustration with patient flow
•
Significant energy and resources expended to facilitate patient flow
and maximize capacity utilization…but with unclear results
©2005 The Chartis Group
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Background and Our Understanding
Top Reasons Clients Focus on PACE
•
Support/enhance patient safety initiatives/further promote safety
as one of the organization’s top priorities
•
Arrest and improve steadily eroding patient and physician
satisfaction levels
•
Achieve targeted volume growth
•
Protect and promote patient sources which could be
compromised by emergent access patients (e.g., elective
procedures)
•
Open additional capacity currently “closed”
•
Avoid/minimize or improve return on investment of planned
capacity expansions
•
Promote ease of access to care as a top priority and
differentiating factor
©2005 The Chartis Group
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Overview of Our Approach to PACE
PACE imparts equal focus on addressing the supply of available beds and the processes that
impact the demand for patient beds.
Key Drivers of PACE Improvement
Bed Supply Management
Achieving maximum bed
availability
• Practices and Policies
• Bed Allocation
• Scheduling
Outcomes
• Increase available
capacity
• Increase capacity
utilization
Bed Demand Management
Results
• Increased physician
satisfaction
• Improved patient
safety
• Increased patient
satisfaction
• Increased volume at
lower capital costs
Unfettered
patient processing
• Intake efficiency
• Discharge and Bed
Turnaround
©2005 The Chartis Group
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Overview of Our Approach to PACE
We view PACE as a series of interdependent complex processes, in which changes in one process
or area can have significant, and potentially unintended consequences, on the whole.
PACE Process Framework
Means of
Access
Bed Management
And Patient Placement
Inpatient Unit
Operations
Pt. Care and
Support Processes
Bed Management Policy
Patient/Bed
Aggregation
Physician
Practices
Bed Management
Processes and Practices
Case
Management
Procedural
and Ancillary
Services
(e.g. Specialty Clinic)
Patient Entry Processes
Staffing
Scheduling
Environmental
Services
Entry Channel 3
Patient Placement
Processes and Practices
Information
Collection
Infection
Control
Entry Channel 1
(e.g. ED)
Entry Channel 2
(e.g. Multiple Others)
Diagnostics
Discharge Planning
Communications
Data, Information and Measures
©2005 The Chartis Group
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Best Practice: Means of Access
Direct Admit:
• Single consistent entry process/path for same day nonemergent admissions
−Consistent points of entry
−Ease of use for admitting MDs
−Consistent service acceptance process built around
facilitating entry
−Consistent unit reception
• Accessible and timely patient transport
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Patient
Care and
Support
Discharge Planning
Communications
Data, Information and Measures
Emergency Department:
• Disciplined definition and use of ED for emergent cases
vs. direct admissions or pre-admission work-up staging
• Consistent service acceptance process built around
facilitating entry
• ED is selectively used as ancillary support after bed
assignment
• Accessible and timely patient transport
Elective Procedures:
• Restructured OR block times to smooth downstream
capacity utilization
• Incentives for surgeons to utilize less popular OR times
©2005 The Chartis Group
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Best Practice: Demand Management
Client Example
Working with the Medical Staff to reorganize surgery schedules can have a significant impact on the
smoothing of downstream demand as it did in this Ortho Unit.
Demand Management in
Orthopedics
Scheduled Daily Admits by Case Type - Before
8
7
6
5
Major
4
Unit ADC Before & After Schedule Changes
Minor
3
2
1
30
25
0
M
T
W
R
F
S
S
Scheduled Daily Admits by Case Type - After
20
Before
15
After
10
Capacity
8
5
7
0
6
5
M
T
W
R
F
S
S
Major
4
Minor
3
2
1
0
M
©2005 The Chartis Group
T
W
R
F
S
S
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Best Practice: Bed Management/Patient Access
Bed Availability (Policy):
• Consistently applied process and definitions for applying
ISO, avoid and private status to patients
• Defined policy for bed closures Consistent approach to
status clearing and communication
• Preventive maintenance scheduled for low census timing
• Clinical/Economic model for bed allocation
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Patient
Care and
Support
Discharge Planning
Communications
Data, Information and Measures
Bed Availability (Process):
• Single consistent centrally managed and accountable front-end process for bed placement/room
assignment and bed closings due to ISO, “Avoid” and Private patient requirements
• Clear responsibility and authority for patient flow and bed management – Single consistent centrally
managed and accountable front-end process for bed placement/room assignment, governance authority for
the new “position” to be effective, clearly articulated relationships with key operational and clinical leadership,
and conflict resolution process that involves and is supported by physician leadership.
• Commonly held decision rules as to patient placement steps, priorities and location
• High census management process – Triggers to alert to approaching capacity thresholds and having
contingency response plans developed to put into play. Clearly defining and communicating the new policies,
procedures and decision-making authority that goes into place during times of high census.
• Daily bed management meetings – Disciplined, daily bed management meetings (support with data,
assure accountability); participants armed with governance authority to be make operational improvements;
clearly articulated relationships with key operational and clinical leadership.
• Bed management/Patient Flow center – track bed (and other resource) capacity and utilization real-time
throughout the institution. Often combined or adjacent to the nurse staffing office and/or admitting. Supported
by new capacity management and/or capacity modeling information technology.
©2005 The Chartis Group
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Bed Management/Patient Access
On average116
beds (14%) are
off-line and
unavailable
each day, with
process
inefficiencies
responsible for
32% of off-line
beds.
Supply: Available Med/Surg/ICU Beds
864
37
32
16
10
8
- 116
Beds
13
748
Total
Available
Beds
Private*
Staffing/Other
Maintenance
Avoids
Isolation
Process
Inefficiency
M/S/ICU
Beds in
Operation
Unavailable Beds
* includes 13100 beds
©2005 The Chartis Group
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Best Practice: Inpatient Unit Operations
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Discharge Planning
Communications
Data, Information and Measures
Patient
Care and
Support
• Unit staffing models constructed to reflect
expected Admission/Discharge/ and Transfer
activities with either:
−Dedicated A/D/T staff
−A/D/T activity built into staff scheduling and
productivity ratios
• Shift scheduling organized to provide consistent
coverage at peak A/D/T times
• Appropriate staff competencies and skill levels on
key units
• Patient discharge status information accurately
tracked and communicated in a consistent and
timely manner
• Fully utilized physical capacity. Key areas include
ED, PACU, OR, ICUs. Staffing to demand, expanded
schedules, better utilized block times
• Case management models aligned with physician
rounding and teaching model to enhance
communications and better expedite patient
discharge
• Nursing, transport and housekeeping consistently
parse non-clinical patient discharge tasks
©2005 The Chartis Group
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Inpatient Unit Operations
CASE STUDY
The solution set contained three fundamental changes.
1.
Development of a centralized “air traffic control”
office that coordinated all bed requests and bed
management related issues at an incremental cost of
$150,000 annually to organization*
Bed
Requests
Staffing
Shortage
Notification
Bed
Closure
Requests
Inpatient
Access
Center
High
Census
Levels
Process
Breakdowns
Bed Status
Changes
• Authority to manage and
enforce newly designed
policies and processes
• Reduction in beds closed
enabling organization to
operate at higher census
levels, absorb more
volume and improve
return on capital
• Reduction in patient
placement times
−Increasing physician
and employee
satisfaction levels
−Promotes patient
safety by more rapidly
expediting care
• Monitor performance and
intervene as appropriate
* Additional costs covered by revenue generated from volume increases
©2005 The Chartis Group
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Best Practice: Patient Care/Support Processes
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Discharge Planning
Communications
Data, Information and Measures
Patient
Care and
Support
• Physician service acceptance and rounding
processes are aligned with operational
requirements of timely effective patient placement
and discharge
• Efficient room turnaround process – “Red,
yellow, green” bed availability notification system,
restructured EVS priorities to make room
turnaround a higher priority, restructured EVS
management so there is a manager responsible for
bed turnaround, SWAT team of EVS focused on
bed turnaround, balancing EVS staffing with bed
turnaround demand.
• Patient transport has consistent dispatch decision rules providing
comprehensive coverage and agreed to prioritization, personnel tracking system to
better utilize transport staff; disciplined, tiered level of personnel utilization, and zone
concept of staff deployment.
• Diagnostic service requirements are flagged and expedited for pending
discharge patients; reprioritized inpatient testing; matching staff to demand, and
simplified ordering process.
• Infection Control actively manages ISO patient definition and clearing process
• All support services staffing will be in alignment with ADT workload (e.g. EVS,
dispatch)
©2005 The Chartis Group
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Patient Care/Support Processes – Managing Peak Times
Inflow
Outflow
Early AM: Peak
bed demand
 Day Shift: Peak
Clinical Activity
Perfect Bed
Placement Storm

Late afternoon: Peak
discharge period
 Afternoon Shift Change
- RN, Transport, etc

Inpatient Discharge Time vs. Admission Time
Weekdays
Percent of Total
12%
10%
8%
Perfect Storm
Peak Bed Demand
6%
4%
2%
0%
0
1
2
3
4
5
6
7
8
Admits
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23
Discharges
Transfers
Source: BPIN
©2005 The Chartis Group
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Best Practice: Discharge Planning
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Patient
Care and
Support
Discharge Planning
Communications
Data, Information and Measures
• Formal physician discharge process designed to facilitate earliest possible patient
departure
• Resident and Attending rounding process scheduled and conducted to facilitate
early discharge of patients
• Clinical/procedural activity schedules constructed with timely discharge facilitation
in mind
• Clear unit-by-unit admit and discharge criteria, with supporting policies and
procedures to make timely transfers happen
• Physician leadership on key units and overall process
• Discharge “lounge” for select discharged patients with prolonged departure waits
• Preferred partnerships with post-acute providers
• Rationalized and integrated approach to planning/facilitating patient transport from
hospital to receiving facility/home
©2005 The Chartis Group
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Best Practice: Info Management/Communications
Entry
Channels
Bed
Management
And Patient
Access
Inpatient
Unit
Operations
Discharge Planning
Communications
Data, Information and Measures
Patient
Care and
Support
• Cascading performance metrics – Key metrics to
manage patient flow performance (e.g., average
discharge time, bed turnaround time, patient
discharge delays, OR room utilization, ED divert
time, etc).
• Management process to manage to the new
metrics – Cascading levels of bed management
meetings. Using a rigorous approach to bed
management meetings (support with data, assure
accountability), with appropriate governance
authority
• Visible, accurate, timely communications of bed status and changes
• Predictive volume model solutions – These models range in complexity from simple PC-based
solutions using standard database software to sophisticated process simulation software packages.
Real-time patient tracking model – Simple database that tracks capacity and demand real-time.
Patient flow weekly forecasting model – Database that includes projected daily demand (from
OR, ED, Admitting etc.) and historical data (ALOS, patient routing and service mix etc.). Used to
forecast what capacity will be over the next 7 days.
End-to-end process simulations – Simulation software that include detailed process
characteristics (patient arrival times frequency, distributions, routings, case times, ALOS, staff and
equipment resources etc.). Used to run multiple “what-if” scenarios.
• Staff availability notification systems – Paging or call systems that track staff location and activity,
and are used to “message” new task orders.
©2005 The Chartis Group
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Best Practice: PACE Management Performance Dashboard
Entry
Channels
1. # Pts Waiting for
Beds
• ED
• Admit Office
• Direct Admit
Unit
2. Wait Times
• ED
• Admit Office
• Direct Admit
Unit
3. ED AMA Rate
4. Hrs ED on Divert
5. ED Admit
Decision to Bed
Discharge Planning
Bed
Management
I/P Unit
Operations
1. Admissions
2. ADC
• Overall
• ICUs
• Key Units
3. Occupancy
• Overall
• ICUs
• Key Units
4. # of Beds
Closed
5. Occupancy
Efficiency
(Midnight/
noon census)
1. Acute ALOS
2. Medicare
ALOS
3. Percent
Travelers &
Agency staff
4. Percent of
patients that
are “longstay”
1. % Discharges by 11:00 AM
2.
Pt Care and
Support
1. I/P Room
Turnaround
Time (TAT)
• Total
• Request
• Turn
2. Patient
Transport
Time
• Total
• Request
• Transport
3. OR Room
TAT
Percent Avoidable Days
Metrics in red reviewed daily by COO
©2005 The Chartis Group
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Approach to Improving PACE Performance
The Chartis Group follows several principles in designing an approach to improving PACE
performance.
• Leadership must drive the PACE redesign and process:
−At the outset leadership and medical staff must have
»a thorough understanding and agreement regarding the goals and expected outcomes
of the effort
»agreement regarding the process, the outcomes, the data and the analyses in order to
avoid endless refinement of data
−Communication should be frequent and consistent
• Staff should design the new PACE process
–Staff have developed a deep understanding of the existing process and the many workarounds required to make it work today. Their knowledge will ensure the new PACE design
will function best
• Data should inform the design process
−Benchmarking must be able to identify the best practices driving performance differences
and assess whether such best practices are applicable to the organization
−Availability of credible internal data and information enables the discussion to focus on
outcomes rather than accuracy of data
©2005 The Chartis Group
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Approach to Improving PACE Performance - Critical Success Factors
In Chartis’ experience, some success factors have been consistent throughout our successful
PACE redesign engagements.
• Look at everything from the patient’s perspective
• Make it a strategic priority
−Active, aligned and ongoing executive and physician commitment and accountability
• Reconstruct and manage processes end-to-end around a specific set of
target outcomes and guiding principles
• Invest in infrastructure:
−Information systems and technology
−A/D/T management personnel
• Develop aggressive, collaborative and coordinated patient placement
policies and processes
• Establish tools, measures and culture to support effective patient access
and bed management
©2005 The Chartis Group
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