October 23, 2012

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It takes a Team

A multidisciplinary approach to managing hospital entry points

Presented by: Maria Antonucci, MS, RN and Susan F. Byrd, RN, BSN, CEN

1926 - American Legion Hospital for Crippled Children

All Children’s Oct. 1, 1967

All Children’s Hospital History

All Children’s HospitalOpened Jan. 9, 2010

April 4, 2011: ACH integrated with Johns Hopkins Medicine 2

• 738,000 Square Feet• 259 Inpatient Beds• 97 Bed NICU

- 35 Bed Level II- 62 Bed Level III

• ACH Heart Center- 22 Bed CVICU- 2 Cardiac Operating Rooms- 3 Cath Labs- Interventional Radiology Suite

• 28 Bed PICU• Vincent Lecavalier Pediatric Cancer and Blood

Disorder Center- 28 Bed Unit: BMT, Positive Pressure

Floor• 12 Operating Rooms & Special Procedures Unit• Outpatient Care Center (OCC): 250,000 sq ft:

physician offices, diagnostic services, laboratory, Ronald McDonald House, Conference Center, administrative offices

All Children’s HospitalOpened Jan. 9, 2010

All Children’s Hospital

3

8,830

73,127

3,345

200

8.0

2.02

Inpatient 2,771

Outpatient 6,482

Cardiac Closed 202

Cardiac Open 226

Cardiac Transplant 4

Cardiac Cath 397

42,080

142,684

137,370Outpatient Visits - Outreach

Surgeries

Average Length of Stay

Case Mix Index (APRDRG)

Admissions

Patient Days

Observation Patients

Average Daily Census

Emergency Center Visits

Outpatient Visits - CampusSource: ACHS Operating Indicators Report

All Children’s HospitalFY2012 Statistics

4

All Children’s HospitalTop 10 Specialties by DischargeFY2012

5

Attend Specialty Cases% Total Cases

Days% Total

Days

PEDIATRIC MEDICINE* 3,144 35.7% 11,960 16.8%NEONATOLOGY* 1,133 12.9% 29,330 41.3%HEMATOLOGY / ONCOLOGY* 1,018 11.5% 7,566 10.7%CRITICAL CARE 609 6.9% 5,957 8.4%PEDIATRIC SURGERY* 571 6.5% 1,970 2.8%GI / NUTRITION 524 5.9% 2,551 3.6%NEUROSURGERY* 429 4.9% 1,797 2.5%PULMONOLOGY 263 3.0% 1,921 2.7%ORTHOPAEDICS 253 2.9% 930 1.3%CARDIOVASCULAR SURGERY* 221 2.5% 3,699 5.2%

Cumulative for Top 10 8,165 92.6% 67,681 95.3%

*Employed physicians

100 Day Workout Methodology

• Supports focus on Pursuing Perfection goals to improve Service, Outcome and Cost

• Action-oriented change model: Rapid-Cycle Testing (RCT)

• Utilizes Lean Six Sigma principles with Just-In-Time (JIT) training

• Brings together teams of managers, frontline staff and physicians

• Improvement ideas and actions plans from teams

• Establishes accountability– Kickoff, 30-60-90 day check-ins, Summation– tool for tracking change ideas and results

What is Lean Six Sigma?

– A combination of two process improvement methodologies:

– Lean involves removing wastes from a process

– Six Sigma involves reducing variation in a process

Patient Flow Workout

• Right patient, right bed, right time

• 60 minutes or less% EC to Appropriate Bed

84.8380.94

65.85

85.4986.77

49.57

56.0358.64

53.54

43.65

73.1171.10 68.08

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Aug-11

Sep Oct Nov Dec Jan Feb Mar Apr May June July Aug-12

Pe

rce

nt

GOAL = 80%

Hospitalist as Gate Keeper

Strategies for Improving Inpatient and Observation Bed Utilization for

Patients Admitted Through the EC

Goals

• Improve utilization of inpatient beds• Decrease the % of reclassified patients to

less than 10%• Improved utilization of CDU beds• Improve patient placement on all referrals to

hospitalist service• Improve collaboration between hospitalists

and EC physicians in the ongoing care of patients not ready for discharge from the EC

Rapid Cycle Test

• Routed direct admits with reduced length of stay to EC

• Had Hospitalist determine next level of care– Clinical Decision Unit– Observation– Inpatient

RCT Outcome

Hospital Observation Census

0.0

5.0

10.0

15.0

20.0

25.0

1 2 3 4 RCTStart

6 7 8 RCTEnd

Week

Ave

rag

e D

aily

Cen

sus

Hospital Inpatient Census

150.0160.0170.0180.0190.0200.0210.0220.0

1 2 3 4 RCTStart

6 7 8 RCTEnd

Week

Aver

ag

e D

ail

y C

ensu

sRCT Outcome

Emergency Center Census

0.020.040.060.080.0

100.0120.0140.0160.0

1 2 3 4 RCTStart

6 7 8 RCTEnd

Week

Ave

rag

e D

aily

Cen

sus

RCT Outcome

0

20

40

60

80

100

120

140

160

180

200

Time in EC Door to Doctor Doc. To Disp.

Pre

Post

RCT Outcome

RCT Outcome

Pre Post Percent dif.Goals1. Decrease the number of observation patients placed in an inpatient unit 105 107 1.9%2. Increase CDU volumes 117 105 -10.3%3. Decrease the volume of Case Management status conversions 0.24 0.17 -29.2%4. Decrease average time in the Emergency Center 172.8 169.3 -2.0%5. Decrease the door to doctor time for the Emergency Center 57.3 55.6 -3.0%6. Decrease the doctor to disposition time for the Emergency Center 99 96.7 -2.3%

What we learned…

• Slight decrease in patient categorized as observation

• No real change in Emergency Center time in department indicators

• Less rework for case management correcting patient status

• Difficulty with Hospitalists’ staffing

CM patient flow workout

• Correct assignment of patient type on admission– Noticed a large number of emails to change status– Most were inpt to obs– Drilled down the obs status– Only 2 status available– Decision to collaborate with teams– Multiple access points identified

Would Case Management in the EC be a better gate keeper?

Would it help meet the needs identified in the CM patient flow workout?

Back to the drawing board…

Assumptions

• If patients have correct assignment of status upon admission:– Right patient in right bed– Increased utilization of CDU– Decrease rework for status change/lean

process

Access case management

Role includes all the functions of the current hospital case managers with the focus being on patients at the point of entry into the hospital.

Hospital entry points

• Emergency Center

• Direct Admits

• Transfers

• Same day surgery

How do we get there?

ROI for EC Case manager

What can they do?

An Access Case Manger can prevent inappropriate admissions, improve discharge planning, decrease cost and enhance patient satisfaction. They can decrease utilization of the EC for non-emergent visits, promote the use of community resources and improve discharge planning to avoid excessive costs.

EC CM staffing plan

• Success = staffing• 7 day/week, 12-hour/day (1100-2300hr) • Salary range average is $34/hr. • 2.1 FTE’s = $148,512 + benefits

Revenue Opportunity

• The LOS = 5 days for non ICU. • Medicaid reimbursement is $2765.69. • One inappropriate admission would cost $8295. • One/week/year would cost $431,340.• Potential to avoid one inappropriate admission

per week = $431,340• 2.1 FTE case manager salaries per year

= $148,512

• Net revenue = $282,828

Opportunity for increase in patient satisfaction, staff satisfaction, quality of care patient flow, bed turnover…

PRICELESS!!!

Goals of position:

The access case manager will be based in the EC working with the multidisciplinary staff in developing a plan of care for the patients. They will be a resource in the decision making process care as it pertains to possible admission.

Other functions

• Facilitate patient flow to correct bed

• Facilitate and expedite testing

• Implement EC discharge planning

• Follow up phone calls

• Patient rounds

Where are we today

• Have 2 positions filled

• Learning to navigate through the EC

• Learning First Net

• Identifying process

• Full roll out planned

Next steps

• Tackle direct admissions

• Entire patient placement center collaboration

Questions ?

• Thank you for listening!