Transcript Hospital and Financial Performance: Improving throughput, flow, and efficiency of care for acutely ill hospitalized patients J.

Hospital and Financial Performance:
Improving throughput, flow, and efficiency of care for
acutely ill hospitalized patients
J. Christopher Farmer
Discussion Points
‣
Framing the issues
‣
Where are we now?
‣
What works and what does not?
‣ How do we identify opportunities for gaining
efficiency?
‣ Methods to improve flow and throughput
‣
Measuring impact
In the hospital:
Where are the biggest bottlenecks?
Emergency
Department
ICU
Step
Down
Unit
WARD
An average “bottleneck” day?
‣ All ICU beds are “full” with medical patients currently in the
CVICU, SICU, and CCU
‣ The intermediate care unit is “full”
‣ Three scheduled CV surgical cases today with one bed opening
“later”
‣ Two patients in the ED require MICU admission (beds)
‣ One neuro-ICU patient transfer request pending (acute stroke)
from the region
‣ Should we go “on diversion” with EMS?
A day in the life of critical care at a
busy hospital…
OPERATING
ROOM SERVICES
POST-PROCEDURE
MONITORING
REGIONAL
REFERRALS
EMERGENCY
DEPARTMENT
“IN-HOUSE”
EMERGENCIES
LOCAL
REFERRALS
CRITICAL CARE RESOURCE DEMAND
1. LIMITED AVAILABILITY RESOURCES
2. MANY DECISION-MAKERS
3. VARIABLE DECISION CRITERIA APPLIED
MICU
CV-ICU
CCU
SICU
WARDS
NeuroICU
“chronic crisis mode”…a global affliction
INTERMED.
CARE UNIT
TELEM.
Fixing these problems every day?
The turning radius of a cruise ship
A critical care reality check…
‣ Most hospitals have enough ICU and acute beds to meet current
demand almost every day…
‣ EMS diversion is a widespread problem
‣ REMEMBER: diversion is not a demand management tool…it is an
excuse!
‣ Diversion = hospital + physician lost revenue (≈ 37,000 USD/pt.)
‣ No data + no physician engagement = CHAOS
‣ So, hospitals build more ICU beds without changing current
practices (a culture change)
‣ This results in little to no net improvement in these problems!
In today’s world--where should tertiary
hospitals be going?
Development of a hospital service
(product) line that meets the internal
and external demands of critical care
and acute medicine
‣ Personnel
‣ Quality
‣ On-site physician coverage 24/7
‣ Data management
‣ Demand management
‣ Education
‣ Fiscal performance
‣ Longitudinal care
What does an acute medicine service
line look like?
 It links the emergency medicine, the critical care, and
hospital medicine physicians into a real or virtual group
 This also should include nurses and inpatient pharmacists
who work in the ICU, step down unit, and involved wards
 It defines protocols and procedures for treating common
serious illness that are followed by all team members

Examples include management of sepsis, pneumonia prevention,
sedation-delirium management, prevention of catheter infections
 It should include hospital management support in order to
track cost, length of stay, quality and safety, etc.
Maximizing hospital throughput
Learn about the “A” team: “prevention”
is better than “predicaments”
‣ Assessment of initial/ongoing need for ICU care [APPROPRIATENESS]
‣ Accuracy of initial/subsequent patient placement [EFFICIENCY]
‣ Accurate and timely decision-making [EFFICIENCY]
‣ Availability of reliable “downstream” resources (intermediate care, telemetry, SNF, LTAC, etc.) [EFFICIENCY]
‣ Assessment and reassessment of physiological status and care requirements [DEMAND MANAGEMENT]
‣ Aggressive development/implementation of care “protocolization” [QUALITY, OUTLIER MANAGEMENT]
‣ Attending physician patient management is on-site (intensivist and hospitalist) [QUALITY, OUTLIER MANAGEMENT]
‣ APN’s and other ancillary personnel (data management, pharmacy, RT, etc.) [EFFICIENCY, DEMAND MANAGEMENT,
QUALITY]
‣ Availability of important clinical and administrative data for “real-time” decision-making (severity of illness, other
clinical, UR, cost) [DEMAND MANAGEMENT, QUALITY, OUTLIER MANAGEMENT]
Planning patient “flow”...
From the front door to the back door
ACUITY OF ILLNESS
ED or
OUTSIDE
REFERRAL
‣ Multiple calls
‣ Transfer delays
‣ Bed availability
‣ Admitting physician
access
ICU
ADMISSION
‣ Multiple calls
‣ Transfer delays
‣ Bed availability
‣ Transfer physician
access
PCU
TRANSFER
‣ Multiple calls
‣ Transfer delays
‣ Bed availability
‣ Transfer physician
access
WARD
TRANSFER
HOSPITAL
DISMISSAL
‣ Multiple calls
‣ Transfer delays
‣ Bed availability
‣ Transfer physician
‣ Multiple calls
‣ Transfer delays
‣ Bed availability
‣ Transfer physician
access
access
Common themes emerge!
‣
‣
‣
‣
Multiple calls
Transfer delays
Bed availability
Admitting physician
access
1. Dependence on individuals, not processes
2. Communications not protocolized
3. Hand-offs not “choreographed”
4. Delayed decision making (dependent on
individuals)
5. Bed management: reacting to requests
versus anticipating needs
6. Not advancing care plans 24/7!
Evolving from demand management
versus demand forecasting
6 hour delay
PATIENT IN THE
ED NEEDS AN
ICU BED
1 day delay
1 day delay
3 day delay
Do you have a bed?
No, call back in
2-4 hours
MEDICAL ICU
No, call back in
2-4 hours
STEP-DOWN
UNIT
No, call back in
2-4 hours
WARD
No, call back in
2-4 hours
Net impact:
‣
‣
‣
‣
‣
‣
5.25 days added to hospital LOS
Additional hospital costs
LOS increases X annual patient load = increased personnel requirement
Increased ICU and Step-down bed requirements
Decreased staff satisfaction (increased frustration)
Quality of care?
NURSING
HOME
Evolving from demand management
versus demand forecasting
Historical number of admissions during each 6 hour
time frame for each day of the week
0600-1200
1200-1800
0600-1200
1200-1800
0600-1200
1200-1800
0600-1200
1200-1800
2400-0600
1800-2400
2400-0600
1800-2400
2400-0600
1800-2400
2400-0600
1800-2400
ED
MICU
Step-down
Unit
Wednesday,
3 admissions
Wednesday,
1 admissions
Ward
Evolving from demand management
versus demand forecasting
0600
ICU
PATIENT
1800
READY
TO GO
READY
TO GO
WHEN...
NOT READY
TO GO
MOVE NOW
ADVANCE THE CARE PLAN
RE-EVALUATE TOMORROW
Adequate Intermediate Care Unit resources:
Not enough = Continuum of care issues…
CRITICAL
CARE
UNITS
FRONT DOOR
‣
‣
‣
‣
‣
‣
BACK
DOOR
INTERMEDIATE
CARE
UNIT
Bandwidth
Care protocols
Triage guidelines
ICU:PCU bed ratios
Provider non-compliance
Patient volume-induced inefficiencies
Defining priorities…
An acute medicine development project…
You need a “team” that will:
‣
‣
‣
Address ICU throughput and resource utilization issues
‣
‣
‣
Address critical care quality and patient safety program needs
Address continuum of care issues
Quantify additional critical care physician and non-physician
recruitment needs (staffing model including coverage
expectations)
Address the role of residents in the critical care units
Develop and advance ICU team functionality (doctors, nurses,
allied health professionals)
think big, start small, go fast…
Address ICU throughput and resource
utilization issues
In order to improve access to ICU beds
‣
patients must be accurately triaged and acuity matched to the correct unit
‣
decision-making criteria (admission & discharge, etc.) must be consistent
and predictable in all units
‣
there must be sufficient numbers of intermediate care beds (also with
disciplined criteria for resource utilization)
‣
a designated physician(s) must oversee processes 1-3 in order to ensure
consistency and compliance
‣
Care protocols and bundles should be used in order to optimize efficiency
Improving throughput: the bottom line…
‣
Our challenge isn’t knowing
what to do to avoid “logjams,”
most have that reasonably
defined…it’s getting it done
(change management)
‣
That’s OK…change management
is difficult for every organization
‣
We need to our spend time
defining priorities along with the
specific strategies to get these
implemented!
‣
No accountability = no durable
change
Intermediate Care Unit
Intermediate Care Unit = Progressive
Care Unit
‣ Should be multi-disciplinary or have
more than one unit
‣ Need more beds relative to total number
of ICU beds!
‣ NO POACHING = NO ICU PATIENTS IN
THE PCU
‣ On-site supervision: ICU teams versus
ward teams
(recommend considering a hospitalist
service)
‣ Need better (and sooner) hand-offs from
the ICUs
‣ Palliative care services
So what do we do?
1. Review historical data: who are the
patients, where are they coming
from, what is wrong with them, what
do they need from us? (but don’t
linger and over-analyze!)
2. Review the “pipeline” from the front
door to the back door…outline
bottlenecks, targets, and then define
specific implementation measures
(we have a lot of what we need
already “on paper”)
3. Create “Top 10” barrier list and
define specific “counter measures”
4. Create a plan of action…2009, 2010,
2012, 2014 (as part of the 1, 3, and 5
year strategic plans)
Historical data review
Performance review
‣
Top 5-10 admission diagnoses to the
ICU’s (stratified by unit)
‣ Which (insurance) payment codes are
linked to these diagnoses?
‣
LOS (hospital + ICU) for each of these
payment codes
‣ Financial performance by payment
code (which of these offer the largest
[positive and negative] margins? What
is our market share for these
activities?
‣ Are there other (not top 10) payment
code categories with small numbers
of patients but strongly positive
margins?
Yes, the details are important...
Protocolized (standardized) management
improves clinical outcomes (published data)
‣Sepsis
‣Acute myocardial infarction
‣Central line insertion and catheter site maintenance
‣Ventilator use strategies in ARDS
‣Ventilator bundle
‣Glucose control
‣Sedation and delirium management
‣Surgical site wound care
‣Daily goals sheet (communications tool)
‣Communications tools for assessment and transfer to
TEAM = SUCCESS
lower levels of care
‣Rapid response teams
‣Multidisciplinary, team-based rounds
‣Use of remote ICU virtual presence monitoring by
intensivists and critical care nurses
‣On-site intensivist program
‣On-site hospitalist program
‣Adverse drug event prevention program
Summary
‣ If you do not know where you are going...any road will get you
there
‣ Recipe for success = plan + timeline + milestones + defined
deliverables + accountable individuals + a strong commitment
from hospital leadership
‣ Think service line for high acuity medicine
‣ Anticipate, do not simply react
‣ Clinical details matter...decreased LOS, complications, mortality