Transcript Employing Lean Flow to Streamline the Admission Process, Improve
Presented by, Matthew Rusk, D.O.
Advisor: Khalid Qazi, M.D.
Objectives
Introduce a concept that augments the admission process by improving: Admission wait times Patient satisfaction Quality Cost Effective Care Explain how change was implemented Discuss results Compare results to current literature
Introduction—Lean Flow
Business concept that is well known and implemented daily by successful businesses Often ignored in the healthcare industry Gaining recognition in healthcare Can make healthcare efficient and improve quality
Introduction
ED overcrowding is associated with worse quality of care and service delivery quality (1); Recent studies have shown clearly that wait time directly affects patient satisfaction (1-9); Time to evaluation can also influence whether or not a patient is seen at all (1, 2, 10).
Hypothesis
Utilizing lean flow will improve the admission process at Sisters of Charity Hospital by: Decreasing the total admission process time Improving patient satisfaction Enhancing quality Improving Cost Effective Care
Methodology
Implementation of Lean Flow X32 Healthcare ‘Rapid Improvement 3-day Program’ ○ CHS Staff; ○ Four Residents; ○ ○ Lean Flow Education; ‘Front end’ Improvements; ○ Little focus on admission process
Methodology
Applied concepts to improve admission process Key Changes: ○ Admission Orders within 30 min; ○ ED Holding Orders in certain situations; ○ Earlier Bed Search; ○ Easier access to order sets, charts and labels
Methodology
Outcome measures Time Patient Satisfaction Quality and Safety Cost Effective Care
Methodology
Pre-intervention March 1 through October 31, 2008-2011 Intervention November 2011 – February 2012 Post-intervention March 1 through October 31, 2012
Methodology-Time Intervals
Arrival ED Provider TAPI Admit Order Departure Arrival to Departure (total admission time) Arrival to ED Provider ED Provider to Time Admitting Physician Informed of admission (TAPI) TAPI to Admit Order Admit Order to Departure
Methodology-Patient Satisfaction
Questions:
Got help as soon as wanted Quiet around room at night Treated with courtesy and respect by doctors Treated with courtesy and respect by nurses Rate Hospital Would recommend hospital to family
Answers 9 or 10 out of 10 defined as perfect score 8 or below defined as non-perfect (negative response)
Methodology-Quality Indicators
Inpatient Specific ED Specific
Fall Rate Left Without Being Seen (LWBS) Core Measure Compliance AMI, HF, PN, SCIP ED Mortality RRT calls Inpatient Mortality
Methodology—Cost Effective Care
Average LOS
ED Volume Total Admissions
Results—Time Variables
Summarized using means and standard deviations. An independent two-sample t-test using assumption of equal variances was used to test for differences in means. A multiple regression model was used to test for differences adjusted for baseline variables (age, gender, race, Arr Method, and Bed Type).
Time Interval Comparison
Time (minutes)
Time (minutes) ( Decrease of 78.8 minutes [417.8 – 339 = 78.8]) Statistically Significant, P-value <.0001
Time (minutes) ( Decrease of 35 minutes [168.5 – 133.5 = 35]) Statistically Significant, P-value <.0001
Time (minutes) ( Decrease of 36.2 minutes [61.9 – 25.7 = 36.2]) Statistically Significant, P-value 0.0015
Summary of Time Variables
Arrival to Departure (Total Admission Time) Decrease of 78.8 minutes 19% reduction in total admission time Most of our overall improvement during TAPI to Dep TAPI to Departure Decrease of 71.2 minutes 31% reduction of this TAPI to Admit Order Decrease of 36.2 minutes 58.5% reduction of this interval Admit Order to Departure Decrease of 35 minutes 21% reduction of this interval
Results—Patient Satisfaction
Summarized using frequencies and percentages. A Pearson chi-square test was used to compare the proportion of satisfaction between pre and post. Odds ratio and corresponding 95% confidence interval was calculated.
Hospital Rating
Chi-square test: Odds Ratio:
Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF
1
Value
1.7981
Value
16.7623
Prob
<.0001
95% Confidence Limits
1.3561
2.3843
Would Recommend Hospital To Family
Chi-square test: Odds Ratio:
Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF
1
Value
1.6931
Value
12.5009
Prob
0.0004
95% Confidence Limits
1.2629
2.2698
Treated With Courtesy and Respect By Doctors
Chi-square test:
Statistic Chi-Square
Odds Ratio:
Type of Study Case-Control (Odds Ratio) DF
1
Value
1.7113
Value
10.0276
Prob
0.0015
95% Confidence Limits
1.2246
2.3914
Treated With Courtesy and Respect By Nurses
Chi-square test:
Statistic Chi-Square
Odds Ratio:
Type of Study Case-Control (Odds Ratio) DF
1
Value
1.7703
Value
11.0264
Prob
0.0009
95% Confidence Limits
1.2606
2.4861
Patient Satisfaction Results
All questions showed significant improvement post-intervention.
Hospital Rating Scores improved to 70.2% (from 56.74%) Recommend to Family Scores improved to 74.94% (from 63.85%)
Results—Quality
Summarized using means and standard deviations An independent two-sample t-test using assumption of equal variances was used to test for differences in means.
Improved Inpatient Fall Rate
Falls significantly decreased (p-value < 0.0001
)
Improved ED Left Without Being Seen (LWBS) 38% reduction in LWBS p-value is < 0.0001
Improved Core Measure Compliance
Percentage of Perfect Care
AMI HF PN SCIP
Pre (%)
91.41
84.35
84.99
84.98
Post (%)
100.00
100.00
94.44
92.61
P-value
0.0956
<0.0001
0.0293
0.0006
Decreased Number of Rapid Response Team Calls p-value = < 0.001
Statistically Significant
Inpatient
Mortality
ED
p-value = 0.9053
No significant difference p-value = 0.6264
No significant difference
Quality Summary
Inpatient Specific
Improved Inpatient Fall Rate
ED Specific
Improved Left Without Being Seen (LWBS) Improved Core Measure Compliance AMI, HF, PN, SCIP No change in ED Mortality Decreased RRT calls No change in Inpatient Mortality
Results—Cost Effective Care
Summarized using means and standard deviations An independent two-sample t-test using assumption of equal variances was used to test for differences in means.
Improved Length of Stay
Average LOS decreased from 4.68 days to 4.36 days (p-value < 0.0018
)
Increased ED Volume and Admissions
ED Volume increased 13.5%: Pre Volume avg = 23,624 Post Volume = 26,799 (March-Oct) Admissions Increased 3.5%: Pre Admission Avg = 4,002 Post Admission = 4,141 (March-Oct)
Cost Effective Care Summary
Improved Average Length of Stay Increased ED Volume Increased Admissions
Discussion
Yale-New Haven Hospital utilized lean and reduced the time from decision to admit [TAPI] to transfer to floor [departure] by 33% (11) Anecdotal recount We had a 31% reduction of this time frame.
Lack of studies focus on admitted patients.
Lack of focus on admission times, affect of overall hospital rating after admission Limited investigation on inpatient quality.
Conclusion
Our study fills void ○ focus on how lean affects the admission process and subsequent hospital stay.
Implementing Lean Flow at Sisters Hospital Significantly Improved Admission Times Significantly Improved Patient Satisfaction Significantly Enhanced Quality Facilitated Cost Effective Care
Conclusion
Further improvements are possible Focus on specific time intervals Re-evaluate processes Lean Flow works and is an essential tool implement in healthcare.
Acknowledgements
Marylin Boehler, RN, Director of ED and Critical Care Julie Morgante, Quality Analyst, Quality & Patient Safety Department Terry Mashtare, PhD, UB Statistics Department Jingjing Yin, UB Statistics Department Entire Sisters Medical Records Department Abid Hussain, MBBS, IM Resident Sameer Waheed, MBBS, IM Resident Mohammad Tantray, MBBS, IM Resident Nancy Roder RN, BSN, Application Analyst, CHS Information Technology X32 Healthcare —Lean Consulting Firm Chuck Noon, PhD Brian Livingston, MD, MBA Jody Crane, MD, MBA Kim Adams, RN
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