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Advancing Strategic Goals through

Hospitalist ExpansionBecker’s Hospital Review April 1, 2019

Carle Foundation HospitalLynne Barnes, Chief Operating OfficerDr. Saad Adoni, MD, Hospitalist Associate Medical DirectorEmily Myers, Manager, Hospital Medicine Physician Practice

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Welcome to Carle

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Mission and Vision

OUR MISSION

We serve people through high quality care,

medical research and education.

OUR VISION

Improve the health of the people we serve by

providing world-class, accessible care through an

integrated delivery system.

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Carle at a Glance

2018

Hospital Beds 413

Average Daily Census 380

Admissions 30,962

Births 2,809

Emergency Department Visits 90,781

Health Alliance Members 230,644

Clinic Visits 824,445

Carle Physicians 597 + 307 APPs

Carle Foundation Hospital

o Level I Trauma Center

o Level III Perinatal Services

o Primary Stroke Center

o Neonatal ICU

o Wound Healing

o Sleep Lab

o Spine Institute

o Heart and Vascular Institute

o Carle Cancer Center

o Mills Breast Cancer Institute

o Bariatric Services

o Palliative Care

o Digestive Health Center

o Carle Research Institute

o Pediatric Affiliation (CHOI)

Carle Physician Group

o Multi-specialty clinic-80 specialties

o Clinical Trials

o Reproductive Medicine

o Oral and Maxillofacial Surgery

o Hearing/Audiology

o Eye/Optical Shop

o Pain Center

o Geriatrics

o Primary Care

Other Business

o Carle Medical

Supply

o Carle Home

Services

Other Business Units continued

o Carle Therapy Services

o Carle Auditory Oral School

o The Caring Place: childcare

o Stratum Med: recruitment, GPO

o Windsor of Savoy: retirement

community

Units

o Carle Sports Medicine

o Carle SurgiCenters:

Champaign & Danville

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A Broad Service Area Receives Clinical Services Through Carle

1,381,170 Carle Service Area Population in 2017

80+Specialties and subspecialties

Level I Trauma CenterLevel III Perinatal

24 bedsCarle Hoopeston

Regional Health Center

134 bedsCarle Richland

Memorial Hospital

413 bedsCarle Foundation Hospital

43+ physiciansCarle Hoopeston

Regional Health Center

10 physiciansCarle Richland

Memorial Hospital

597 physiciansCarle Foundation Hospital

44 APPsCarle Hoopeston

Regional Health Center

10 APPsCarle Richland

Memorial Hospital

307 APPsCarle Foundation Hospital

10,816 ED visitsCarle Hoopeston

Regional Health Center

9,633 ED visitsCarle Richland

Memorial Hospital

90,781 ED visitsCarle Foundation Hospital

6 countiesIn West Central IN

29 countiesIn East Central IL

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Carle Service Area Health Alliance Network

230,994Total Lives

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Dyad Leadership is a "work" marriage combining administrative leader with a physician leaderThe partners balance skills and strengths and work as a cohesive team towards common goals.

ADMINISTRATIVE LEADER

o Management skills

o Clinical credentials

o Persistent, organized, detailed

o Relates well across organization

COMMON GOAL PHYSICIAN LEADER

o Sterling clinical credentials

o Excellent relationship and influence skills

o Systems thinker

o Develop department and high-performing team

o Establish effective communication between admin and physicians

o Solve complex department problems

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• Historical Successes, Struggles, and Engagement

• Establishing the Hospitalist as leaders in Safety, Quality and Service

• Future program goals.

Agenda

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Successes, Struggles, and Engagement

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Success: Whiteboard Rounds

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Success: 2018 Committee ParticipationCommittee Name Hospitalist Representative

Surgery PPC, IP Best Practice Adoni, Saad

Inpatient Diabetes Committee Afzal, Ommar

Fall Reduction Workgroup Ahmed, Mohammad

Medical PPC, Chest Pain Accreditation Alcaraz Jr , Renato

Hospitalist Physician Wellness Alcaraz, Ellaine

Stroke Program Committee Al-Heeti, Ommar

Medical PPC Are, Chaitanya

Inpt best practice committee Arwari, Andy

UPC Rog 6 Asapu, Eswara

High Quality Dysphagia Chakumgal, Sreenu

Observation Meeting Elman, Arnolfo

Inpatient Sepsis Multidisciplinary WorkgroupGao, Lianghe

Triage RN Monthly Staff Meeting Ginne, Purshotham

Carle Mortality Committee Gong, Chunling

IP Best Practice Grindem, David

Antimicrobial Stewardship Committee Haider, Baqer

SNF collaboration readmission and discharge Hashmi, Nazneen

UPC NT6 Hsu, Sean

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Struggle : Staffing

• Patient volume growth at the same time of not hiring up to demand– Physicians committed to ~100 extra shifts per month

• Short over 10 FTE’s – Created a need for those to work extra shifts

• Increased Physician burnout

• Doubling or splitting teams to address gaps in coverage

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Struggle : SchedulingPhysicians Self-Scheduling

Allowed for Flexibility in Shift Preferences• Days, evenings, nights, etc

Created multiple 1-2 day gaps in coverage• Increased # of hand-off’s between day rounding teams

• Increased LOS for our patients

• Patient Dis-satisfier

• Nursing Dis-satisfier

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Struggle: Efficiency

• Average starting census was 15-16 patients with total encounters of 18.

• Large gap between discharge efficiency and starting census

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Struggle -The Metrics

•ALOS

•CMI

•Readmissions

•Patient Satisfaction

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Average Length of Stay

Target

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Case Mix Index (CMI)

Target

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Readmissions

Target7%9%

11%13%15%17%19%21%

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July

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2016 2017 2018

Readmission Rate

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Patient Satisfaction Scores

Target

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Establishing the Hospitalist as leaders in Safety, Quality and Service

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Hospitalist Mission Statement

The Carle Hospitalist Institute is comprised of a group of physicians dedicated to providing evidence based care and striving to be the agents of safety and quality for the patients we serve.

We are here to provide leadership for the patient experience, as well as serve as role models for compassionate and accountable care leading to the best possible outcomes for Carle Hospital patients, their families, the care team, and the community.

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Hospitalist Vision

Carle Hospitalist Institute’s vision is to lead Carle Hospital toward top decile performance across all quality and service metrics through leadership and care rigor.

Our team will be viewed as the leaders of care within our hospital reflecting a physician led and patient centered culture that draws the best and brightest of providers and staff.

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Scheduling• One week on, one week off block scheduling, all shift

types

• Change to 7am to 7pm Scheduling

• Limit to 1 shift in 24 hour period

• Change of Service Days will be Wednesdays

• All Hospitalist Patients equally distributed

• Reset on Unit Integrity

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Scheduled Shifts• Standardization of the Swing Shifts: Three 10-hour swing

• 4pm – 2 am• Standardize the Nocturnist Shifts

• Night Triage• Cross-Cover• Night Admitting Shift

• Backup• No backup.• If calling in sick, physician expected to seek their own

back up coverage.

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Operational Improvements

• Day Rounding expected to have 2 admits until 5pm.

• Equal Distribution of all patients admitted by swing or Nocturnist Hospitalist

– Equal Distribution trumps Unit Based Integrity

• All “Census Cap” Policies will be removed

• Hospitalists arrive at the designated time for WB rounds

• Remain available and onsite to patient load from 8a –5p

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Operational Improvements

• 3pm huddles for all the Rounding Teams

– UNL, Care Coordinator

• Discharge summaries completed and EPIC inbasketqueries responded to prior to leaving shift

• Combined Admin / Quality Meeting to promote networking and collegiality

– Offsite and after hours to increase attendance

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Sweet Spot Revisted

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Physician Satisfaction• Equal overnight distribution

• Incentive to discharge patients

• Lower starting census– From 16 – 18 patients to 12 – 13 patients

• More time to spend with patients

• Work on discharge summaries for today/ tomorrow

• More structure, less stressful days– Lower potential for physician burnout

• Increased collegiality between group

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What’s Next…

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One Pipeline Process

• All transfer patients from the region assessed in Observation designated unit prior to admission

– Includes Regional Referrals, PCP office, Conv. Care

• Triage Hospitalist accepts the patient

– The triage hospitalist screens the patient upon arrival. This is the added step that confirms the patient condition matches the current bed placement plan. Care orders initiated/consults are contacted as appropriate.• Physician Response Time: 20 minutes

– Case Management reviews inpatient criteria

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One Pipeline Process

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Documentation Improvement Resources

• On-Site Clinical Documentation Information training session for physicians

– Group format with lead physician trainer

• 2 CDI physician leads within Hospitalist Group

– Training and feedback for Hospitalists

• Monthly feedback on opportunities and data

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Improving WB Rounds

• Physician Led

• Focus on day to day care

• lacking sense of ‘urgency’

• Undefined date of discharge– “2-3 days”

• Nurse- Physician Led, new scripting

• Focus on discharging patients

• Targeted LOS for diagnosis and current LOS

Previous: Future:

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Transitional Care Clinic• Outpatient intervention-post discharge clinic.

– Transitions in care from an inpatient hospital setting to the patient’s home.

– Patients will be seen within 72 hours post discharge.

– Targets high-readmission risk patients.

• Staffed by Hospitalists, extension of the inpatient stay

• Success:– Reducing readmissions to hospital within 30 days

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Enhancing Relationships/ Communication

• Partnership Council

– Raise awareness and success for Hospitalists as the Quality and Safety Champions in the Hospital

– ED Physician, Critical Care physician, Nursing Leadership, Case Management, Triage RN, Patient Experience Team

• Nursing / Case Management Survey

– Gain feedback on Hospitalist program• Perception

• Availability

• Efficiency

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Carle Board ReportKey Metric Description and Rationale 2018 Baseline 2019 Target 2019 YTD

ALOS

Average Length of Stay for Inpatients: A lower LOS typically 

indicates more efficient use of resources and reduces the risk

of hospital acquired conditions for patients. 4.86 3.87 4.73

Observed : Expected

Length of Stay

Based on CMS benchmark LOS; this is how Carle compares

with similar patient types for length of stay.  The closer to 1.0,

the more accurate the length of stay comparison. 1.25 1.12 1.20

Case Mix Index (CMI)

The measure of the acuity of a patient derived from the

documentation provided by the physician. A higher CMI

indicates higher acuity and resources needed to treat the

patient. 1.43 1.50 1.53

Discharge Efficiency

The average number of patient discharges divided by the

total number of patients on an individual physician panel.  

This is a measure of a particular physician’s effectiveness in

helping a patient move through their course of hospital care. 21% 25% 22%

Readmission Rate

The number of patients discharged from the hospital who

return to the hospital for an admission within 30 days. 18% 15% 19%

3PM Huddles

These daily huddles take place on each unit in order to

facilitate any needs for the patient and/or family before the

rounding physician leaves for day. This “huddle” provides an

opportunity for any nursing or patient/family care questions

to be addressed in person by the physician.

The “huddle” also drives discharge by focusing on patients

discharging today or tomorrow. 0% 80% 100%

Hand off Note compliance

These notes provide any meaningful information that should

be conveyed to the next physician who is taking over care of

the patient, both overnight and each week when the

physicians transitions on and off service. 0% 80% 100%