Bay Pines Carey Award Journey

Lithium Lin, MD, Chief of MedicineKaren McGoff-Yost, LCSW, Program Analyst, Surgery ServiceDebi Bailey, LCSW, MPH, HSS, Geriatrics and Extended Care

Bay Pines VA Healthcare System

Carey Award SymposiumOctober 2010

• Waits and Delays• Bay Pines on Divert >50% in winter

months• Quality of Care not optimal

A Problem in 2004

33

What are the symptoms when you don’t have Inpatient/Hospital Flow?

• Hospital Closure/Diversion• Patients diverted to another Hospital• Higher Fee Cost• Overcrowded ER• Patients sitting in the ER/hallways for hours

• Delayed Procedures• Cancelled Surgeries• Gridlock• Angry Patients• Stressed Staff• Poor Outcomes• Patient Safety Affected• Waste of Resources

What are some ways to Improve Flow or do Inpatient System Redesign?

Build more beds & hire more staff (expensive)

Analyze, improve processes/communication & target resources/incentives

(efficient)

44

A Closer Look at the Problem in 2004

Bay Pines Medicine ALOS = 6+ daysInterQual on BDOC only about 60%

Everybody had an anecdote as to why pt did not meet criteria

Everybody was pointing their finger at someone else

6

Bad Delays vs Good Delays

• Waiting a few days for inpatient to recover from pneumonia before surgery is a good delay

• Waiting a few days for OR availability because of poor planning, poor communication, etc is a bad delay.

• Work to reduce bad delays

66

Concept of Avoidable DaysBed Day of Care that could have been

avoided if the system operated optimally

Often self-evident in CPRS chartingE.g. “Await Surgery input”, “Await CT

results”, …

Drill DownsThe need to drill down to meaningful

and actionable data

The need for UR Nurses and Hospital Managers to provide constant

feedback to each other

99

Radiology Avoidable DaysPart I

• By 2005 at Bay Pines, we realized Radiology was #1 inpatient delay.

• And CT was #1 delay within Radiology• Improved TAT with expanded hours• Hired additional staff

101010

Avoidable Days due to CT Scans

Avoidable days due to CT ScansFY 2005- FY 2008

0

10

20

30

40

50

60

70

80

90

100

Q1 Q2 Q3 Q4

Quarters

Nu

mb

er

of

Avo

idab

le

days

FY 2005 FY 2006 FY 2007 FY 2008

11

Avoidable Days due to CT Scans: 2005 vs. 2008

12

Radiology Avoidable DaysPart II

• We then redesigned inpatient CT ordering to scanning process

• We later also implemented Off Ward Policy which had other collateral benefits

• Essentially now we have CT on Demand

131313

Old Flow Chart

14

Several Hours may

pass

Pt. may not be in

room

If pt. not available, CT cancels test

w/o informing anyone

New Flow Chart

15

Off Ward Policy

• Implemented in 2007• Updated and strengthened in 2009• Reduced off ward patient injuries• Improved monitoring, infection control• Side benefit of improved flow

161616

17

18

Nuclear Medicine Avoidable Days Part I

• The next most important delay was Nuke Med• Avoided 2-day tests in favor of 1-day tests• Expanded Nuclear Medicine Services for OP

on Saturday, which aided IP; particularly helpful on 3-day weekends

1818

191919

Avoidable Days due to Stress Tests: 2005 vs. 2008

20

21

Nuclear Medicine Avoidable Days Part II

• Variability in inpatient nuclear stress test demand

• Working on predicting demand based on season, weather, DOW

• Working on alternatives such as DSE

2121

22

Cardiology Avoidable Days Part I

• Paid OT for Echo Techs to come in on Saturdays

• Worked with Cardiologists to read Echos on Saturdays

• Now working on after-hours Echo

2222

Cardiology Avoidable Days

232323

Avoidable Days due to ECHOs: 2005 vs. 2008

24

25

Cardiology Avoidable Days Part II

• Improved throughput through Cath Lab• Mostly Interventionalist dependent• Improved EMS turnover of the lab also helped• Now building 2nd Cath Lab

2525

Cardiology Avoidable Days Cont’d

262626

Avoidable Days due to Cardiac Caths: 2005 vs. 2008

27

28

Radiology Avoidable Days

• Most of the improvements in other areas of Radiology came from service agreements & building capacity

• For example for PET scans, service agreement outlined who can order what test.

2828

Radiology Avoidable Days Cont’d

292929

Avoidable Days due to MRIs: 2005 vs. 2008

30

Radiology Avoidable Days Cont’d

313131

Coumadin/Heparin Regulation Avoidable Days

• Unexpected top delay in 2008• Found Hospitalists tended to keep patient

longer than necessary• Moved Coumadin regulation responsibility

from Hospitalist to Pharmacist

323232

Coumadin/Heparin Regulation Avoidable Days

• Automatic Pharmacist consult generated when Coumadin is ordered on a patient

• Coincidental with Joint Commission Patient Safety Goals

333333

Coumadin Avoidable Days

343434

GI Avoidable Days

• Cost-benefit analysis did not favor routine GI procedures on weekends

• But weekend GI pts did not get their procedure til Tuesday

• Improved weekend communication btw Hospitalist & GI so pt got procedure 1st thing Monday AM

353535

Avoidable Days due to Colonoscopy/EGD: 2005 vs. 2008

36

Results: Decreased LOS Medicine Service

373737

Further Interventions Resulting in Reduced Avoidable Days (Medicine)

383838

Contributors to ALOS reduction

• Hospitalists unwedded from wards• Hospitalists wedded to teams• Improved Inpatient Continuity of Care• Increased Hospitalist & Patient Satisfaction• Improved Flow

393939

Medicine Admissions• Linear increase in admissions from FY 2002 to FY 2009

40

Increased acuity levels in patient population based on Continued Stay Review (UR) data

414141

42

FY 2009-2010 OMELOS data: Lower is Better

4242

Diversion Rates• Improvement of Hospital Diversion/Closure rates from

FY 2006 to FY 2010.

434343

Incentives

• Admission Meeting Criteria and ED Flow Measures are part of ER Physicians’ Performance Pay Goals

• Also part of provider-specific data for recredentialing

• Daily feedback given by UR Nurses

444444

Incentives • Hospitalist Performance Pay Criteria includes key

factors as well– Continued Stay Meeting Criteria– ALOS– Readmission within 30 days– ED Flow Measures– Combined rank of ALOS, D/c before noon,

Readmission rates• Avoidable Days part of Medical Specialists’

Performance Pay– i.e. Avoidable Days due to Echos for Cardiologists

454545

Flow Initiatives at BPVAHCS

• Home Page Icon• Bed Czar• ED Bed Board• IP Bed Board• Expansion of ED• Expansion of telecapacity by converting Gen

Med beds to tele-capable

464646

474747

Home Page Icon•Place on Facility Home Page signals its importance to staff•Easy to tell at a glance whether the facility is open (green), divert (yellow) or closed (red)•Most up-to-date status•No more confusion

Bed Czar

•Position officially called Bed Flow Coordinator•Works much like Air Traffic Controller•Also Manager of Bed Management System; Runs daily VISN Bed Huddle Call

Emergency Department Information System

•ED Bed Board•Can track reasons for ED Stay >6H•Bed Czar can anticipate admission and get beds ready•Managers can tell at a glance whether there is gridlock from number of patients with significant ED LOS

Bed Management SystemInpatient Bed BoardAvailable on everyone’s desktopsInformation at your fingertipsInformation such as bed filled/vacant, gender, isolation, telemetry, LOS, etc.No bed-hiding

Flow Initiatives at BPVAHCS: Changes

• 2AM Lab draws • Off ward policy

• Bedside PT

• Discharge Appointments and DC<12PM Incentive Programs

52

• Streamlining Admission Workgroup

• Scheduled Discharge Shared Governance Team

• Discharge Planning Brochure

• Outpatient Pharmacy Buzzer

5252

Delays For Days of The Week

53

Utilization Management Committee Membership

• Jeffrey Abraham, MD, Chief, Emergency Room

• Larry S. Atkinson, MD, Chief, Primary Care Service, Co-Chairperson

• Terri Baio, Program Specialist, Fiscal Service

• VyVy Corpe, LCSW, Social Work Supervisor

• John Frutchey, MD, Chief, GEC Service• Lithium Lin, MD, Chief, Medicine

Service, Co-Chairperson• Ressa McDonald, Physician,

Pulmonary Section• Sharadchandra Patel, MD, Chief

Hospitalists • Trey Reed, MD, Chief, Fee Basis• Tifphani Valdes, AO, MH&BSS

• Rene Wilson, Supervisor, Health Administration Service

• Thea Wilson, Patient Flow Coordinator (Bed Czar)

• Diane Aldridge for Terry Wright, MD, Chief of Surgery

• Nicole Arnold, Acting Chief, Health Administration Service

• Maxine Dent, Quality Systems• Joanne Elkins, Chief, Quality System• Donna Henderson, Chief, Health

Administration Service • Karen McGoff-Yost, Program Analyst,

Surgery Service• Sola Osinbowale, Administrative

Officer, Medicine Service• Debra Williams, Chief Nurse

Med/Surg

545454

Return on Investment

Avoidable Days Cost SavingsProcedure 2005 2008 % Reduction

2005-2008Cost Savings

CT Scan 307 57 81% $263,193

Stress Test/Thallium

480 219 54% $280,488

Echos 271 84 69% $247,478

Cardiac Cath 418 60 86% $538,100

MRI 167 56 66% $93,808

Colonoscopy/EGD 267 80 70% $168,808

55

Total Cost Savings

56

Return on Investment Cont’dFY 2005 & 2009 DRG and Cost Info

DRG 2005 ALOS

2009 ALOS

Difference Avg. No. Discharges

Avg Cost BDOC

Savings

COPD 4.89 4.13 -0.76 362 $1575 $433,314

Pneumonia 6.87 5.26 -1.61 247 $1575 $625,062

Heart Failure 5.44 4.26 -1.18 367 $1969 $851,317

Cardiac Arrhythmia

3.52 3.33 -0.19 251 $1969 $93,878

Renal Failure 8.11 5.04 -3.07 126 $1575 $606,824

57

Total Cost Savings

58

Salary & Benefits of UM Nurse

59

VA-TAMMCS & Baldridge

• V = Vision = leadership sets organizational goals (Baldridge Criteria 1&2)• A = Analysis = prioritize key processes vs. key business drivers, project

selection, benchmarking• T = Team = who touches the process? Employee/Customer/Stakeholder

Engagement (Baldridge Criteria 3 & 5)• A = Aim = what to accomplish? how will success be defined? Timeframe?• M = Map = depict your process visually until all team members agree this

is the actual current process (Baldridge Criteria 6)• M = Measure = gather data, base further steps on actual objectified data,

not anecdotal (Baldridge Criteria 4 & 7.5)• C = Change = pilot changes, continually re-assess• S = Sustain & Spread = deploy throughout organization, build in

mechanisms for ongoing tracking, staff training

Mental Health Systems Redesign at Bay Pines VAHCS

How It Started:HSM trainee in need of a project +Leadership Support from COS who just

completed IHI course +Problems with Psychiatry Diversion = Bay Pines 1st Mental Health Systems Redesign

Project

Acute Care Mental Health Rate of Closure & Diversion

Average of 9 hrs per day

on divert or closed

BPVAHCS Acute Care Mental Health Patient Flow

Patient referred from

community

Patient referred from primary care or

mental health clinic

Patient is a walk in to ED

Patient is assessed by ED Psychiatrist

on Duty (POD)

Does patient need Mental

Health admission?

Patient treated by ED POD

Patient discharged with appropriate follow up care

and/or community resources

Is patient medically cleared for admission?

No

Yes

Patient treated for medical condition

Does medical condition require

admission?

Treated in ED by medical physician

and released to POD for Mental

Health admission

No

No Yes

Bed assigned by bed control

Patient transported to mental health

ward

Patient admission work completed by

ward staff

Yes

Patient treated by assigned Psychiatrist

and treatment team

Patient ready for

discharge?

No

Disposition plan determined by treatment team

Disposition plan enacted

Yes

Pharmacy completes orders for discharge

medications

Social Work completes

discharge and transportation

notes

Psychiatrist completes discharge orders and

discharge summary including any appointments for follow

up psychiatric care

Patient admitted to medicine or surgical ward

Nurse completes discharge and communicates

discharge instructions to patient

Does patient need

institutional care upon discharge?

Does patient need

substance abuse

treatment upon discharge?

Does patient need a

residence upon

discharge?

Social Work1. Determine income level2. Make referral to institution(s)3. Assist patient and/or family w ith placement decision

Social Work1. Residential or outpatient?2. Make referral to VA programs3. If VA cannot accept make referral to community programs4. Assist patient and/or family w ith placement decision

Social Work1. Determine income level2. Offer community resources3. Discuss options w ith patient and/or family4. Assist patient and/or family w ith placement decision

Does patient need

transportation to discharge

location?

Patient discharge complete

NoIs transpotation available once

nurse is complete?

Yes

Patient remains admitted until transportation

available

No

Patient discharged and transported per discharge plan

Yes

FY 06 Acute Care Mental Health Admissions and Discharge Data

by Day of Week

8.3%

16.3% 16.5%

18.7%

14.6%15.0%

10.6%

0.0%

22.6%

18.0%

20.2%

18.2%

20.7%

0.4%

0%

5%

10%

15%

20%

25%

SUN MON TUE WED THU FRI SAT

% o

f M

en

tal

He

alt

h A

dm

iss

ion

s/D

isch

arg

es

% of Admissions % of Discharges

Discharge Data from ProClarity Discharge Cube vhaaacdw04,vha.med.va.govAdmission Data from Fileman routine

Flow Out - Day of Discharge

Time from Discharge Order is Written to:Pharmacist completes medication counseling

1.1 hours

Nurse completes discharge instruction 3.2 hours

Patient leaves ward: DELAYS Travel Meds not ready Waiting on lunch

6.0 hours

Recommendations • Daily communication

– bed status– UR findings

• Regular monitoring and communication of key patient flow measures • Weekend discharges

– Psychiatrist work schedules• Evaluate POD coverage hours • Establish open access day treatment program • Analysis/System Redesign of Residential Substance Abuse Treatment

Program– Analysis of potential community resources to provide dedicated beds

for a substance abuse residential treatment program.

After

Before

FY09: Flow Map for RRTP Admission Process

Current MH SRD Projects

• STP – decrease wait times for consultation• Gero-Psych DTP – change programming based

on customer feedback while decreasing wait times for program admittance

• DRRTP – maintain gains from FY09 project• Follow-up to the original project – Inpt Psych

open 62.5% in FY06, up to 82% in FY10; LOS decreased 56%

Surgical Systems Redesign

at Bay Pines VAHCS

WHO WE ARE

Bay Pines VA Health Care System is a Department of Veterans Affairs Level 1A Complexity Hospital Providing Primary, Secondary and Tertiary Care at our main campus in Pinellas County, and community clinics serving 11 counties along the Florida Gulf Coast

Last year, Bay Pines served over 100,000 unique veterans with nearly 1 million visits

Our Operating Room served 4,500 surgical patients last year during FY10

While some VA’s across the country are seeing declining workload, our facility continues to grow and thrive

WHERE WE WERE: The State of our Operating Room

Cases started lateTeam not synchronizedExcessive delaysExcessive Overtime $$Poor communicationErratic workloadIneffective Change

Strategies – Lack of an Improvement Framework

Decisions were influenced by:Who yelled the loudestWho complained the mostAnecdotal evidenceFinger Pointing/BlamingInternal Politics

THREE KEY STRATEGIES1. Use of the Critical Path Method to improve

OR Cases Starting on Time 2. Use of Variability Methodology to smooth

out admissions patterns, to help keep our hospital off divert and insure surgical beds available when needed

3. Use of Variability Methodology to smooth out the OR Schedule, which has reduced day to day variation in workload AND shown huge improvement in overall OR Utilization

Yes

No

Yes

No

No Yes

Yes

No

No

Yes

Yes

Total Time (min.) 27 33.5 46 33 60

Holding Area Nurse checks ID. Correct patient? 1

Patient returns to ASU.

RN Circulator checks for allergies, implants. 1

RN asks if family/people waiting. Verifies ride home. 1

Surgical staff called to mark site. 1

Holding Area RN verified lab, blood availablity.1

Holding Area Nurse verifies consent form. 1

Anesthesiologist greets pt. and checks pt. ID. 1

Anesthesiologist confirms type of surgery. 0.5

Anesthesiologist reviews pt. hisotry. Includes acid reflux/hernia eval. 2

Patient currently fasting? 1

OR Nurse rolls in case cart and required equipment. 8

Are Case Carts Complete? 3

Scrub set up sterile field.Equipment checked for function. 12

Surgical counts done.Implants verified.8

Patient data reverified by RN Applies compression device. 5

Send instruments to SPD, obtain new instruments if available.

Surgeon checks pt. ID and surgery. 0.5

Surgeon insures consent signed and correct. 0.5

Surgeon marks surgical site on patient. 1

Surgeon enters note. 5

Surgeon verifies w/OR for correct instruments. 5

CRNA retrieves medication for sedation. 5

CRNA sets up their part of OR. 10

Pt. arrives to Holding Area. 1

Pt. leaves Holding Area

RN opens supplies. Instruments properly prepared? 3CRNA checks pt.

ID. Performs pt. interview. 5

CRNA Reviews medical record and pre-operative assessment. 5

Anesthesiologist inserts IV if needed. 8

OR Nurse Staff Meeting. 20

Pre-Operative Flow Chart

FY09 Primary Improvement Technique: VARIABILITY METHODOLOGY

• Used tools from Litvak Spreadsheet and applied to OR caseload

• Goal to reduce daily variability from mean• Will continue to use this technique with goal of furthering

smoothing out peaks• Showed a 4% reduction in day to day variability as

measured by Mean minutes OR in use; a few days of large outliers can significantly disrupt the Mean

• New Metric: the number of days each month that OR workload (minutes that patients are in the OR Suite each day) has a 10%+ variance from the mean workload

• Underlying goals of maximizing OR utilization are to eliminate backlogs/improve access to care and to decrease overtime/improve staff morale by having schedule completed on time, without running over.

• Upon analysis, we realized that our initial Aim was faulty: overall Utilization could appear “good” (a “high” percentage) but day to day variability in caseload would keep underlying problems from being abolished

• Day to day variability a patient safety risk

Variability Factors• Analysis of Add-On cases• Divide Add-Ons into Emergent, Urgent, and Non-Emergent Add-Ons• Standardize terminology across staff so data can be collected and

analyzed. Review of cases form February 2009 revealed that cases entered into the system as a certain type did not use same definition.

• March 2009: Meeting with Program Analyst, OR Nursing and OR clerk: definitions now standardized.

• Truly Emergent and Urgent Add-Ons cannot be avoided – however, the pattern of these cases can be reviewed to determine if it is random or non-random

• Random: Apply Queuing Theory to determine when Emergent Block Time Needed/how many rooms

• Non-Random: i.e. cases in certain scheduled clinics, need to re-allocate block time to when these cases are more likely to need intervention

Week Day

# of Elective (surgical) Admissions Average Deviation

# of Emergent (ED) Admissions Average Deviation

1 Monday 6 6.6 0.6 12 13.45 1.451 Tuesday 8 6.6 1.4 15 13.45 1.551 Wednesday 10 6.6 3.4 13 13.45 0.451 Thursday 6 6.6 0.6 10 13.45 3.451 Friday 5 6.6 1.6 12 13.45 1.452 Monday 5 6.6 1.6 15 13.45 1.552 Tuesday 4 6.6 2.6 19 13.45 5.552 Wednesday 5 6.6 1.6 14 13.45 0.552 Thursday 4 6.6 2.6 15 13.45 1.552 Friday 7 6.6 0.4 11 13.45 2.453 Monday 8 6.6 1.4 16 13.45 2.553 Tuesday 8 6.6 1.4 17 13.45 3.553 Wednesday 8 6.6 1.4 9 13.45 4.453 Thursday 10 6.6 3.4 17 13.45 3.553 Friday 7 6.6 0.4 12 13.45 1.454 Monday 7 6.6 0.4 13 13.45 0.454 Tuesday 8 6.6 1.4 18 13.45 4.554 Wednesday 5 6.6 1.6 14 13.45 0.554 Thursday 9 6.6 2.4 13 13.45 0.454 Friday 2 6.6 4.6 4 13.45 9.45

TOTAL 132 269

AVERAGE 6.6 13.45Sum of absolute Deviations 34.8 51

Ratio of Absolute Deviation 0.68

Ratio of Relative Deviation 1.39

Week Day

# of Elective (surgical) Admissions Average Deviation

# of Emergent (ED) Admissions Average Deviation

3/10/2008 Monday 5 7.4 2.4 8 12.5 4.53/11/2008 Tuesday 7 7.4 0.4 12 12.5 0.53/12/2008 Wednesday 7 7.4 0.4 11 12.5 1.53/13/2008 Thursday 9 7.4 1.6 14 12.5 1.53/14/2008 Friday 8 7.4 0.6 20 12.5 7.53/17/2008 Monday 5 7.4 2.4 12 12.5 0.53/18/2008 Tuesday 5 7.4 2.4 10 12.5 2.53/19/2008 Wednesday 10 7.4 2.6 13 12.5 0.53/20/2008 Thursday 7 7.4 0.4 21 12.5 8.53/21/2008 Friday 8 7.4 0.6 17 12.5 4.53/24/2008 Monday 5 7.4 2.4 12 12.5 0.53/25/2008 Tuesday 11 7.4 3.6 7 12.5 5.53/26/2008 Wednesday 9 7.4 1.6 9 12.5 3.53/27/2008 Thursday 7 7.4 0.4 12 12.5 0.53/28/2008 Friday 7 7.4 0.4 12 12.5 0.53/31/2008 Monday 5 7.4 2.4 12 12.5 0.54/1/2008 Tuesday 6 7.4 1.4 15 12.5 2.54/2/2008 Wednesday 11 7.4 3.6 15 12.5 2.54/3/2008 Thursday 7 7.4 0.4 9 12.5 3.54/4/2008 Friday 9 7.4 1.6 9 12.5 3.5

TOTAL 148 250

AVERAGE 7.4 12.5Sum of absolute Deviations 31.6 55

Ratio of Absolute Deviation 0.57

Ratio of Relative Deviation 0.97

Surgical Admits (Scheduled: Dispo from PACU)

date SICU 3C boarder total

9/1 2 2 0 49/2 2 6 0 89/3 2 4 0 69/4 1 1 0 29/8 0 2 0 29/9 2 3 0 59/10 1 3 0 49/11 1 5 0 69/14 1 4 0 59/15 2 3 0 59/16 2 5 0 79/17 3 3 0 69/18 1 2 0 39/21 1 1 0 29/22 2 4 1 79/23 2 6 0 89/24 3 1 0 49/25 1 5 0 69/28 1 4 0 59/29 3 2 0 59/30 2 5 0 7total 35 71 1 107

avg/day 1.666667 3.380952 0.047619 5.09524

Surgical Admits By Specialty (Scheduled)

date Ortho Gen Vasc Uro ENT GYN Thoracic Plastics Podiatry Oral Surg total

9/1   2 2               4 Tues9/2 2 3   1     2       8 Wed9/3 2 2 1 1             6 Thurs9/4   1 1               2 Fri9/8 2           1       3 Tues9/9 1 3         1       5 Wed

9/10 1 2 1               4 Thurs9/11 1 2     2     1     6 Fri9/14 2   1   2           5 Mon9/15 2   2 1             5 Tues9/16 2 2   1     2       7 Wed9/17 2 1 1 2             6 Thurs9/18   2 1               3 Fri9/21 1   1               2 Mon9/22 2 3 2               7 Tues9/23 2 1   3     2       8 Wed9/24 1 1 1 1             4 Thurs9/25 1 1 1   1       2   6 Fri9/28 3   1   1           5 Mon9/29 2   3               5 Tues9/30 2     1     2 2     7 Wedtotals 31 26 19 11 6 0 10 3 2 0 108 % of

admits 28.7% 24.1% 17.6% 10.2% 5.6% 0.0% 9.3% 2.8% 1.9% 0.0%  Admits by Day total/day avg/dayMondays 12 4Tuesdays 24 4.8Wednesdays 35 7Thursdays 20 5Fridays 17 4.25

OR Variability: Lower is BetterJanuary 2010 average daily variation = 287 minutesMonthly total = 5,456 minutesThis is ~13.5% reduction in variability over baseline

last year.Improved, but have not met goal of 25% reduction in

variabilityThere is still day to day variability within Sections

scheduling, and this is now being trackedAdd-Ons are not entirely random, and our change of

time dedicated for Add-On cases has helped tremendously, and has allowed us to absorb the high utilization of Vascular Surgery

Actual Pattern of Add-On Utilization vs. Scheduled Block Time for Urgent Cases

0

200

400

600

800

1000

urgent block time add-ons in minutes

Patterns (based on review of all cases from February 2009)

• Average 3.63 Add-Ons per day; this represents ~20% of OR cases

• Although Wednesdays and Thursdays have blocked time for Urgent cases, only 29% of add-ons take place on those days.

• Add-Ons most likely to occur on Fridays (31%)• Nearly 80% of Add-Ons are truly urgent, emergent and/or

patient is already in the hospital (needs a 2nd surgery, or surgery consulted by Medicine)

• 75% of Add-On cases are already in the hospital, or being admitted through the ED; 20% were outpatient before surgery and 5% came from LTC ward.

• Just over 20% of Add-Ons were those that could have been electively scheduled

Areas for Improvement• Currently, OR has block time set aside for Urgent/emergent

cases on Wednesday and Thursday afternoons• Amount of time blocked has been inadequate, as well as

timing of when block time for Urgent Cases should be• Analyze urgent-emergent cases and re-allocate block time:

the time equivalent to 1 room per day is how much time on average we spend on Add-Ons

• Distinction between number of Add-Ons (more cases also creates higher burden for EMS & SPD) and case length in minutes of Add-Ons (how much time they take away from scheduled cases or create overtime)

• Other efficiency strategies to increase Utilization will remain: measure and reduce delays, 1st cases starting on time, turnover time as quick as safely possible

Total Minutes OR in Use 3912Total Minutes OR Staffed/Scheduled for URO 5,220OR utilization % 74.9%

date day time blocked time used n cases %util/daily1/1 Fri 0      1/4 Mon 0      1/5 Tues 450 98 2 21.8%1/6 Wed 450 262 5 58.2%1/7 Thurs 390 391 3 100.3%1/8 Fri 0      1/11 Mon 0      1/12 Tues 450 273 4 60.7%1/13 Wed 450 390 5 86.7%1/14 Thurs 390 413 5 105.9%1/15 Fri 0      1/18 Mon 0      1/19 Tues 450 381 7 84.7%1/20 Wed 450 357 5 79.3%1/21 Thurs 450 258 4 57.3%1/22 Fri 0      1/25 Mon 0      1/26 Tues 450 470 6 104.4%1/27 Wed 450 383 5 85.1%1/28 Thurs 390 236 4 60.5%1/29 Fri 0      

TOTAL 5220 3912 55

Late Running Cases vs. OR UtilizationJanuary 2010

date dayminutes OR

utilized (pt in room)

deviation from mean

% OR Utilized w/out TT

% Utilized WITH TT

number cases total

number rooms

running > 3:30pm

total case length >

3:30 pm (in minutes)

1/1 Fri 1/4 Mon 2200 10.9 69.8% 84.1% 17 1 111/5 Tues 1342 847.1 42.6% 48.2% 14 0 01/6 Wed 2718 528.9 86.3% 102.2% 22 4 4391/7 Thurs 2337 147.9 85.6% 101.7% 18 4 521/8 Fri 1950 239.1 61.9% 73.3% 15 2 29

1/11 Mon 2207 17.9 70.1% 87.8% 21 2 2201/12 Tues 2518 328.9 80.0% 93.2% 20 2 1871/13 Wed 1956 233.1 62.1% 72.3% 18 0 01/14 Thurs 2084 105.1 76.3% 92.5% 18 2 1191/15 Fri 2912 722.9 92.4% 109.0% 19 5 5601/18 Mon 1/19 Tues 2192 2.9 69.6% 80.7% 18 1 281/20 Wed 2387 197.9 75.8% 90.2% 21 3 581/21 Thurs 2091 98.1 66.4% 76.5% 17 2 1041/22 Fri 2611 421.9 82.9% 97.3% 19 3 1651/25 Mon 1729 460.1 54.9% 64.9% 16 0 01/26 Tues 2062 127.1 65.5% 79.9% 21 2 941/27 Wed 2537 347.9 80.5% 97.2% 24 4 3951/28 Thurs 1671 518.1 61.2% 70.2% 15 0 01/29 Fri 2089 100.1 66.3% 81.6% 19 2 254

TOTAL 41593 5455.9 NA NA 352 39 2715AVERAGE 2189.1 287.2 71.1% 84.4% 18.5 2.1 142.9

*AFTER HOURS/WEEKEND/NIGHTTIME EMERGENCIES EXCLUDED. PRIME TIME ONLY.

OR Utilization

This was our primary FY09 Improvement Project. Analyzed add-on pattern, backlogs, utilization

patterns, admissions, etc. Revised OR Block Schedule. Changes took effect September 1, 2009 September 2009 OR Utilization (w/out Turnover Time) = 71% Up nearly 15% from Quarter 1

Specific Successes since FY09 Baseline

GYN Utilization up 31.1%Thoracic Surgery utilization up 27.1%Urology Surgery utilization up 23.7%Vascular Surgery Utilization up 22.5%ENT Surgery utilization up 21.2%Plastic Surgery utilization up 17.1%Gen Surg, Ophth & Ortho about the

same

The range of OR Utilization among specialties improved greatly: the range of Utilization in FY09 was 16.2% to 85.2%; in FY10YTD the range is 50.4% to 111.4%. None of these include Turnover Time, which only increases the calculated utilized time(s).

For the last 3 years, the OR has been able to meet the

increase in workload with our improvements in efficiency –

no change in OR Nurse staffing or space.

For the last 3 years, the OR has been able to meet the

increase in workload with our improvements in efficiency –

no change in OR Nurse staffing or space.

Supporting Indicators

• OR First Cases on Time (DUSHOM MONITOR)

• Overtime Costs (AVOIDABLE VS UNAVOIDABLE)

• Turnover Times • Cancellation Rate• Reduce Reasons for Delays• Keep Admissions Patterns Smooth• Surgical Backlogs• Cycle Time from decision to perform

surgery to OR date

Additional Successes Changes in 1st Case Wheeled In on Time have been

sustained Earlier in the day ward discharges fewer delays

moving patient out of PACU due to no inpatient bed Internal targets for Marking Times met Stable, low cancellation rate Extremely low rate of internal diversion

Defined as scheduled surgical admission having to be boarded in a non-Surg ward bed

No cases cancelled due to lack of an available hospital bed

New Aims/Goals

• Measure PACU Bottlenecks and Reduce• Increase Discharges by 10AM• Reduce Cycle Time from identification of

patient as a surgical candidate OR Date• Streamline pre-operative process to reduce

work-up costs• Standardize order sets• Eliminate non-value added steps in work-up

Continued Challenges• Bottlenecks due to peaks in ASU Census

– We can smooth the surgical schedule but other specialties (Cardiac Cath Lab, Interventional Pain, Interventional Radiology, etc) are all trying to schedule into the same recovery bed space

• Encouraged & Incentivized Day-Before Discharge Orders – DC Orders written the day before did NOT improve time patient left the next day

• Unable to make further gains in Turnover Time while EMS short-staffed

FY10 Improvement Project (in process)

Address Out-Of-OR cases Need to smooth out invasive procedures

across the medical center Requests for Out-Of-OR Anesthesia Services

have increased 250% in one yearCompetition among Services for

AnesthesiaRecovery Beds (ASU & PACU)Transporters

Journey from Inpatient

Home and Community Care

to

Scheduled Discharge Workgroup

Formed in 2006 to meet Performance MonitorScheduled discharges with Interdisciplinary Team effortsLearned that patients were happier with communicationDischarge Incentive Award program to get staff buy-in

System Redesign Principles:Used PDSA and RPIW techniques

Performance Improvement with Scheduled Discharge Monitor

Performance Improvement with Scheduled Discharge Monitor

Streamlining Admission Workgroup

Formed in June 2007 to review all systems related to admissions and failing performance measure

Baldridge Principles: Leadership, Strategic Planning, Customer Focus,

Process Management

System Redesign Principles: Process Mapping, Eliminate waste,

Streamlining Admission WorkgroupChallenges: Not all patients come through ERMany come from CBOC or other clinicsThere is no standardized process for intake of these patientsNot all patients come through ERMany come from CBOC or other clinicsThere is no standardized process for intake of these patients

Streamlining Admission WorkgroupCreated Patient Flow Center as a cost-effective and targeted solution

Performance Measure addressedHub for patient flow coordination.Bed Czar and bed control coordinate admissionsStreamlines patient flow and eliminates waits and delays.Patients being admitted from Primary Care and outside facilitiesUse of Express Card to track progress

FAR-VISIONFrequent Admission Reduction of Veterans by Investigating

Social Issues & targeting Outpatient NeedsGrew out of Utilization Management CommitteeUsed UM database that was already created

Baldridge Principles: Data Management, Process management, Results

Goals:Prevent readmissionReduce Frequent Admission patients

FAR-VISIONChallenges:

About 800-900 unique patients at Bay Pines are admitted 3 or more time within 12 months, adding up to about 40% of our inpatient admissionsNumber of admissions has grown more than 30% over the last few years, more than 10% in this year aloneReducing Inappropriate Admissions & BDOC is reaching point of diminishing returnsNeed to look at reasons this group is a “frequent admission” Need to develop a way to analyze this group and target our interventions to these high cost patients

FAR-VISION

Accomplishments:

CPRS pop-up alertDaily email alert & monthly comprehensive spreadsheet in shared folderSocial Work Assessment ToolAccess Database created to analyze dataCreated a Directory of Healthcare Resources accessible by link on Bay Pines homepageDecreased readmissions about 2% for this population

FAR-VISION

FAR-VISION

FAR-VISIONLiving Environment

FAR-VISIONEducation Level

FAR-VISIONSubstance Abuse Type

FAR-VISIONMiscellaneous Factors

FAR-VISION

TLC Collaborative National Collaborative that had Bay Pines look at working

together to meet the goal of decreasing re-admission for the “frequent admission” population

Used Utilization Management Committee data Medicine and GEC working together Referrals to Community & Home Based Care Programs

VA TAMMCS PrinciplesVision-Analysis-Team-Aim-Map-Measure-Change-Sustain - Used a systematic process for success

TLC CollaborativeChallenges: HBPC in limited counties HBPC may reach capacity CCHT has challenges with Primary Care buy-in Staff do not know about GEC programs Late discharge planning by hospital teams Need for skilled care Homeless patients Unsafe living conditions in patients’ homes

TLC CollaborativeAccomplishments: LTC attends daily morning interdisciplinary rounds Renewed interest in CCHT from Endocrine, Pulmonary and

Cardiology for diabetes, COPD and CHF patients All patients on HBPC generate VERA dollars ~ $26,000 per

year Request for Proposal submitted and awarded for FY2010-

FY2013 for ‘Discharge Clinic’ HBPC awarded grant to expand into Southern catchment area

and outlying rural areas Initiative by Chief of Medicine for identification of frequent

ED patients

Total BDOC Pre & Post HBPC

CCHT Readmissions

Post Hospital Transitional CareCreate an Ideal Transition Home by:Creating Discharge Clinic Team:

Consists of: Nurse Practitioner, RN Case Manager, SW Case Manager, and RN Patient/Staff Educator

Short and long term case management services that begin prior to discharge

Post discharge follow up within 1-3 day discharge from acute care

Discharge Clinic will see patients prior to PC appointment for follow up and interventions

Reduce 30 day re-admission rates by 10 % for identified frequent admission patients

Post Hospital Transitional Care

Decrease readmission rate for Chronic Diseases COPD, CHF, Diabetes by 5-10% in frequent admission patients

Decrease ER visits for frequent admission patients

Improve patient education

Improve Handover Communication with PC

Improve Veterans overall health

SAFE HOMESecure After-hospitalization through Follow-up,

Education, Hand-Off & Managing Exigencies

Transformation of Scheduled Discharge Workgroup

Baldridge Principles:Customer Focus, Data Management, Results

System Redesign Principles:Process mapping, Eliminate Waste

VA TAMMCS

SAFE HOME

Goals: 100% of discharges have follow up appointments Improve and standardize discharge summary Improve Patient education Restructure pharmacy discharge instructions Discharge brochure and video

Challenges: Multiple disciplines involved in process

Ongoing process Medication Reconciliation Patient Education Handover Communication Timely Follow-up with Primary Care Continuation of increase of NIC programs Education to staff about availability of programs Looking at data to improve and start new programs Mental Health, Medicine, Social Work, and GEC working

together

Where are we going from here?

Frequent ER VisitsSome patients are seen 15-20 times in the

ER each year.At this frequency, the ER is not really

providing emergency care but providing chronic care/primary care.

Challenge: Meet needs in a more patient centered way.

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Frequent ER Visits

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Frequent ER VisitsAt Bay Pines, there are 66 patients with 12 or more ER

visits within the past year

168 patients with 9 or more ER visits in 1 year

503 patients with 6 of more ER visits in 1 year

Initially, frequent ER visitors will be described as patients with 6 or more visits in a year.

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More about these 500 patients at Bay Pines

• Approximately 7 are OEF/OIF veterans• Approximately 35 don’t have PC providers, so they

were quickly assigned• Top diagnoses related to mental, cardiac and

pulmonary conditions• Only ~ 15% enrolled in an intensive OP management

program (i.e. MHICM, CHF, COPD, HBPC, CCHT, etc)

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More about these 500 patients at Bay Pines cont’d

• We continue to analyze these patients– Bay Pines ED averages 75 encounters each day

• Approximately 11 are Frequent ED Visitors

– Analysis of their admission rates, time of day of ER visits, etc. continues

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Frequent ER Visits

ER is not a good setting for chronic/primary care because:

Can be a chaotic setting

Different providers each visit

Not conducive to longitudinal care

High cost visits

Promotes ER crowding133

Frequent ER Visits

After patient is determined to not have an acute emergency, the goal is to redirect the patient to a

better setting for chronic/primary care.

Our goal is to reengage the patient in an alternate setting which can:

Deliver quality care to the patientTake a longer-term approach to the patient’s health

Be a more productive environment

134

RE-ENGAGE Initiative

Repeated ER Encounter Game-plan for Alternate Care-Giving Environments.

Reengage the frequent ER visitor in an alternate setting which delivers better quality healthcare to the patient with a longer-term

approach/outlook.

135

Interesting Fact

• Only 15% of Frequent ER Patients are enrolled in an intensive outpatient management program such as MHICM, CHF, COPD, CCHT, HBPC, etc

• Could intensive outpatient management program help some of these patients?

136

RE-ENGAGE Strategies

• System of Alerts include CPRS pop-up alert – A daily alert is being developed (ties in with Patient

Centered Medical Home initiative)

• Standardize brief list of questions & education package in ER.

• Identify alternate settings more appropriate for patient & try to reengage the patient there.

137

ED Survey Questions

138

RE-ENGAGE Strategies

• Identify possible low-cost/high-return investments (if any).

• Identify gaps in the system which lead patients to resort to ER for non-emergent care.

• Develop metrics. (No national measures on this).

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System Redesign (SR) Initiatives

• Emergency Department (ED)• Avoidable Days• Surgical Flow• Mental Health Redesign• Scheduled Discharges• FAR VISION• SAFE-HOME• RE-ENGAGE

140

Baldrige Principles in our Success• Leadership

Make decisions around and support culture of key drivers (quality, access, safety, satisfaction, efficiency)

• Strategic Planning In addition to VHA strategic initiatives, local planning is aligned and prioritized by

key drivers• Customer Focus

Insure new processes are patient centered• Data Management

Use for decision making (prioritizing), improvement evaluation and improvement maintenance and back to decision making

• Workforce Focus Increased training in redesign theory and collaborative training and use of trainees,

volunteers, students and high-performing individuals with stretch assignments, insure “grass roots” included

• Process Management Use various mapping tools to insure that process is efficient and all agree on how

process should be carried out• Results

Questions/Comments?

For any questions regarding the System Redesign Initiatives at the Bay Pines VAHCS, please contact the following staff:

Karen McGoff-Yost @ karen.mcgoff-yost@va.gov for Surgical Flow

Debi Bailey at debra.bailey@va.gov for GEC/TLC Initiatives Sola Osinbowale @ olusola.osinbowale@va.gov for Medicine

Tifphani Valdes @ tifphani.valdes@va.gov for Mental Health142

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Thank you for allowing us to share our journey….

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