11/27/2013

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C4: The Improvement Opportunity in

Real-time Location Systems

Dennis S. O’Leary, MD Marilyn P. Chow, RN, PhD, FAAN

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Presenter Disclosures

• Dennis S. O’Leary, MDo President Emeritus of The Joint Commission

o Chief Medical Officer, Awarepoint Corporation

• Awarepoint is one of a number of RTLS companies

• Marilyn P. Chow, RN, PhD, FAANo Vice President, National Patient Care Services, Kaiser Permanente

• No conflicts to disclose

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Learning Objectives

• Explain the basic design of a Real-time Location System (RTLS).

• Describe three RTLS applications that address patient safety issues.

• Provide two examples of data-based improvement opportunities in the typical Emergency Department.

• Describe two ways in which RTLS supports significant cost reductions.

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Primary Goals for Healthcare Technology Solutions

• Quality Healthcare Deliveryo “Delivering compassionate, high quality, affordable healthcare

services.”

• Cost Managemento “Creating efficiencies, reducing costs, and streamlining clinical

and business processes.”

• Risk Mitigationo “Mitigating financial, operational, and clinical risks.”

• Process Improvemento “Identifying utilization and performance improvement

opportunities throughout an organization.”

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The Battle to Improve Patient Safety: Are We Winning?

• Significant preventable adverse events occur in one in every 7-10 hospitalized patients.

• Over 2 million healthcare-acquired infections are identified each year.

• Medication errors harm at least 1.5 million people (400,000 in hospitals) every year.

• Level of harm incidents (25 per 100 admissions) unchanged over 6 years.

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Top Hospital CEO Concerns

2010 2011 2012

Financial challenges 1 1 1

Patient safety and quality 4 3 2

Healthcare reform implementation 2 2 3

Government mandates 3 3 4

Care for the uninsured 6 5 5

Patient satisfaction 7 7 6

Physician-hospital relations 5 6 7

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The Multiple Faces of Waste… and Safety Exposures

• Steps in a process that add no value

• User-unfriendly hospital design

• Illegible prescriptions

• Avoidable patient re-admissions

• Decubitus ulcers, patient falls

• Management of common conditions, e.g., low back pain, depression

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Problems andImprovement Opportunities

• Quality of Careo Wasted nurse time looking for equipment, constrained direct patient care

time, long order to care delivery time, patient and staff satisfaction issues

• Cost Managemento Suboptimal asset utilization; lost, stolen, misplaced equipment; capital

budget redundancies; excessive rentals

• Risk Exposureo Ineffective equipment recall and PM management processes; reduced

temperature monitoring compliance; preventable hospital acquired infections

• Missed Opportunitieso Ambulance diversions / ED patients LWOT, OR case delays, slow bed

turnover

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Real-time Location Systems (RTLS) Defined

• Wireless technology that permits the tracking of moveable medical equipment, patients, and staff inside hospitals

• Include applications for monitoring and managing care workflow in discrete locations (e.g. OR, ED), for temperature monitoring, and for monitoring hand hygiene

• Have enterprise-wide coverage capacity of over 4 million square feet

• Produce data-based outcomes that empower evidence-based decision making

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RTLS Data Flow

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RTLS Technologies (Active)

• Radio Frequencyo WiFi

o ZigBee

• Ultrasound

• Infrared

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5 Critical Success Factors

1. Enterprise-Wide Coverageo Assets and people move throughout the organization. Optimal

improvement requires complete overview of location, status and movement

2. Room Level Accuracyo Crucial to enable long-term clinical and financial outcomes

3. Non-Disruptive Installation and Low Ongoing Maintenanceo Minimal operational disruption, systems’ interference, and IT burden

4. Standards-Based Interoperabilityo Allows 3rd party integration; scalable solution supports current and future

needs

5. Proven, Flexible, Low Risko Referenceable ROIs, flexible business model

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WiFi Channel Utilization

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2400

MHz

2483.5

MHzIEEE 802.11b (WiFi)

Channel 1 6 11

2412 2437 2462

WiFi Deployment Optimized for Data Throughput

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1 6 11

1 6 11

1 6 11

6 11 1 6

1 6 11 1 6 11

Good Channel Utilization

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WiFi Deployment - Accuracy vs. Bandwidth Tradeoff

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1

6

6

11

1

6

11

1

6

1

6

11

1

11

6

1

11

6

1

6

11

1

6

Best Channel UtilizationWorst Channel Utilization

Worst Location AccuracyBest Location Accuracy

WiFi Pros and Cons

Pros Cons

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• Everyone has a WiFi network

• Provides accuracy within 3-9 meters (10-30 feet)

• Perceived as an easy entry- point for RTLS

• Not enterprise wide

• Not room-level accurate

• Difficult to install and maintain

• Consumes bandwidth on mission-critical network

• Requires additional technology (ultrasound, infrared, etc.) to drive clinical workflow

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ZigBee Channel Utilization

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2400

MHz

2405 2410 2415 2420 2425 2430 2435 2440 2445 2450 2455 2460 2465 2470 2475 2480 2483.5

MHz

IEEE 802.15.4 (ZigBee)

Channel 11 12 13 14 15 16 20191817 21 22 26252423

2400

MHz

2483.5

MHzIEEE 802.11b (WiFi)

Channel 1 6 11

2412 2437 2462

ZigBee Wireless Sensor Network (WSN) – Room-Level Accuracy

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Flexible Deployment, Self-Forming Multipoint Calculation

Continuous Calibration, Self-Healing

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ZigBee Pros and Cons

Pros Cons

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• Enterprise Wide

• Room- and bay-level accurate

• Easy to install

• Easy to maintain: auto-calibrates, self-heals

• Redundant

• Doesn’t interfere with mission-critical WiFi network

• IT-centric buyers want to use WiFi (don’t understand challenges with accuracy, etc.)

• Represents a second wireless network

Infrared Technology

An LED transmits infrared signals as bursts of non-visible light; a photoreceptor detects the light pulses

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Infrared Pros and Cons

Pros Cons

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• Good room-level accuracy

• Complements WiFi strategy

• Poor enterprise-wide coverage

• Some technology requires hard-wiring

• Difficult to “tune” for accuracy

• Tag failure rate is high (mechanical, battery life)

• Can be “shielded” by blankets, clothing, etc.

Ultrasound Strategies

An oscillating sound pressure wave with a frequency greater than the upper limit of the human hearing range

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Ultrasound Pros and Cons

Pros Cons

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• Good room-level accuracy

• Complements WiFi strategy

• Poor enterprise-wide coverage

• Difficult to “tune” for accuracy (though less difficult than Infrared)o Strategic hardware placement

helps

• Can have “shielding” issues

Asset Management: Key Financial and Clinical Outcomes

Tracking

• Improve Staff Productivity | Minimize Risk (Recalls, PMs, Sterile Process)

Rentals

• Control expenditures

Utilization

• Optimize inventory levels

Shrinkage

• Reduce lost, misplaced, stolen

Temperature Monitoring

• Actively monitor | Reduce loss or misuse of temperature sensitive asset

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Kaiser Permanente• 7 regions serving 8 states and the District of Columbia

• 9.1 million members

• 16,000 physicians; 174,000 employees (including 48,000+ nurses)

• 38 hospitals

• More than 600 medical offices (ambulatory care buildings)

• $50.6 billion operating revenue (2012)

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Current RFID Use Cases Installed

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Active RFID Tag Adoption at KP

Production

Total Asset Tags ~147,000

Temperature Sensors: ~6,500

Wireless Location Coverage: ~32,000,000 Sq Ft

Active RFID (RTLS)• Asset Tracking• Equipment Maintenance• Asset Management• Rentals• Equipment Loss/Shrinkage• Temperature Monitoring• Infant Safety

Passive• Retained

Foreign Objects

Active RFID Geographical Activity

0

25,000

50,000

75,000

100,000

125,000

150,000

2009 2010 2011 2012 2013 2014

Implementing

Historical Timeline Kaiser Permanente has a long history with RFID, which has recently become a prevalent infrastructure

RFID Data Collection

RWJF Time and Motion study,Marilyn Chow and

Ann Hendrich

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Asset Tracking Pilot

LA Medical Center

RWJF Time and Motion study,

Marilyn Chow and Ann Hendrich

Journal Article

Asset Tracking

5+ Sites

Tracking & Temp

Hawaii

Garfield RTLS Purchase

Asset Tracking,

Temperature

18 Sites

Tracking &

Temp

Mid-

Atlantic

Purchase

SmartCareIntro

Time & Motion

S. Sacramento, Roseville

Tracking &

Temp

NCAL Triplets

Passive -

OR Sponges

Care-FusionIV Pump Purchase

Labor Mgmt Collaboration

Active RTLS introduced to healthcare roughly around early 2000.

NCALSCAL

1st NCAL Site Live

San Jose Med. Center

SelectedAsset Tracking Standard

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Value of Room Level Accuracy

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15’ Distance Error - Wrong Room 2’ Distance Error – Room Level Not Applicable

5’ Distance Error - Correct Room 3’ Distance Error – Wrong Room

Enterprise Reporting Goals

• Optimize equipment inventories by site, region, enterprise, etc.o Opportunities to reduce excess purchasing

o With improved visibility, start to identify largest aggregated overages/shortages and prioritize them first

o Use overages to address shortages enterprise wide

o Minimize time from request for additional equipment to decision

• Find equipment that migrated

• Better national / regional program planning

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Enterprise DB

Medical Center A

Medical Center B Medical Center C

Medical Center D

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Enterprise Reporting Versus Local

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Local Reporting Enterprise Reporting

Reporting ScopeSingle hospital with support

buildings

All buildings by hospital

including support buildings

Target coverageSelective; hospital, then

prioritized buildings

All hospitals and medical

offices

Support for national purchasing,

project planningLimited Yes

Identify unofficial equipment

migrationsNo Yes

Data consistency Helpful Critical

Coverage consistency Helpful Important

Location consistency Helpful Important

Enterprise system integration

readinessUnlikely Critical

Differences

Requirements

Temperature MonitoringAutomated Temperature Logging and Notifications

• Temperatures logged and reported automaticallyo Medications • Blood Bank • Specimens • Breast Milk •

Solution Warmer • Food/Nutrition • Glucose Tolerance • Pathology • Blanket Warmer

• Corrective actions logged for out of compliance readings

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• Notifications automatically sent for rising (or falling) temperatures to prevent loss and increase patient safety beyond regulatory requirements

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Radio Frequency Objects Identified “Making Counting Count”

• Improve accuracy & reliability of counting by detecting retained gauze surgical items

• Improvements in Culture of Safety by augmenting Highly Reliable Surgical Team (HRST) practices with Technology

Retained Foreign Objects

Zero Gauze-Related RFOs since early 2013 Go-Live

Now, exploring expanding to non-Gauze RFOs.

Team Simulation to Evaluate

Potential Vendors

Facility Based Pilots To Test Product &

Processes

Rapid Launch &

Rollout

Unified RFID VisionIn the operating room today, multiple RFID tags = multiple, competing sensors which lead to erroneous readings and confusion for clinicians

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Problematic RFID example Our Vision One sensor supports multiple tags

sensor

tag

Vendor 1

Vendor 2

Vendor 3

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Summary of Lessons Learned• Reduces a burden on employees who spend time finding

equipment.

• Medical equipment maintenance goals are more easily achieved.

• Room level accuracy is of great importance to part time users; to keep it simple and easy to understand.

• Provides more accurate information on real time equipment quantities for hospitals, MOBs and for roll up reporting.

• Enterprise data consistency will promote roll up reporting and less complex integration work.

• Reduces equipment loss while helping to provide information on how equipment is lost.

• Enables 24x7 temperature monitoring with notifications

• Design the location infrastructure assuming multiple use cases

• Future looks bright – a lot of potential for quality improvements

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Joint Learning Session with

Frontline Staff

To collaboratively learn about RTLS and explore how it might improve our work

on the frontlines

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Use Case #1: Summoning Staff

for In-room Assistance

Current State

Nurses often need in-room assistance from other staff for such tasks as patient repositioning and medication witnessing. To receive this help, they must leave the patient room and spend time searching for staff throughout the unit.

With all nursing staff wearing RFID badges, the technology can allow a single RN to know who is nearby, and then summon that individual to assist in patient care activities.

Win: Saved Time

Future State

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Asset Management: Key Financial and Clinical Outcomes

Tracking

• Improve Staff Productivity | Minimize Risk (Recalls, PMs, Sterile Process)

Rentals

• Control expenditures

Utilization

• Optimize inventory levels

Shrinkage

• Reduce lost, misplaced, stolen

Temperature Monitoring

• Actively monitor | Reduce loss or misuse of temperature sensitive asset

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Tracking Capabilities

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The interface is intuitive, offering simple, one-click

searching capability

Staff can see exactly where equipment is located –anywhere throughout the facility using any network-connected computer

Understanding Equipment Misuse and Root Cause

Opportunities:• Compliance / Monitor /

Alert

• Optimize workflow, e.g. identify bottleneck area / type

• Reduced dwell time: cost savings on reduced asset inventory

• Best Practice: Aggregated results and ranking from multiple customers

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Fluid Pump State Changes (10% Procedure Violations)

Patient

Room

(2d)

Clean

Hold

(9hr)

Dirty

Hold

(7hr)

Cleaning

(1d)

2%

1% 0%

5%

15%

11% 12%

14%18%

19%

1%

1%

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Automated Equipment Flow Audit Trail

Opportunities:• Compliance / Monitor /

Alert

• Optimize workflow, e.g. identify bottleneck area / type

• Reduced dwell time: cost savings on reduced asset inventory

• Best Practice: Aggregated results and ranking from multiple customers

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Fluid Pump State Changes (10% Procedure Violations)

Patient

Room

(2d)

Clean

Hold

(9hr)

Dirty

Hold

(7hr)

Cleaning

(1d)

2%

1% 0%

5%

15%

11% 12%

14%18%

19%

1%

1%

Safety AlertSafety AlertPCA Pump 33647 (Tag 09939)

With a status of “Dirty”

Entered 11-1105A

At 04/21/2009 14:32

Automated Workflow: Surgery

Milestones

• Quantify (track) the linear progression of the patient encounter

• Standard to all patients in a unit (e.g., all OR patients in a unit have the same milestones)

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Automated Workflow: Surgery Milestones Based on Location

Patient Flow Metrics Productivity Metrics

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• Check in to Pre-op arrival

• Pre-op arrival to

• Patient prep completion

• Anesthesia evaluation

• Surgeon Pre-op visit

• Patient prep completion to OR arrival

• OR arrival to surgery start

• OR arrival to OR departure

• OR ready for PACU to PACU acceptance

• PACU clearance to departure

• Patient wait times across care areas

• Total patient prep time required by case type

• On-time case starts

• OR Suite turn around time

• Time duration between cases

• OR holding time

• PACU holding time

• Transport response time

• Patient duration in each care area (by procedure type)

Automated Workflow: Milestone-Driven Surgery Notifications

Patient Flow Notifications Productivity Notifications

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• Wait time thresholds

• Incomplete preparation steps (H&P, labs, IV access, etc.)

• Ready for Anesthesiologist

• Ready for Surgeon

• Time delay thresholds for clinician assessments, preparatory steps

• Ready for Surgery

• PACU readiness to receive patient, assigned bay

• Equipment par levels (pumps, SCDs. Case carts, etc.)

• Case at risk of exceeding expected duration

• Missing clinicians for case

• Transport notification upon PACU disposition documentation

• Housekeeping notification upon disposition documentation

• Dwell time for holding patients across care areas

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Automated Workflow: ED Milestones Based on Location

Patient Flow Metrics Productivity Metrics

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• Check in to Triage

• Triage to Bed

• Bed to Nurse Assessment

• Door to Doc

• Door to CT/ECG

• Order to procedure (Lab, Rad)

• Call light to response

• AMI arrival to Fibrinolytic Therapy

• AMI arrival to PCI

• (Equipment dependent) order to execution

• Total Triage time

• Door to discharge/admit (LOS)

• Decision time to discharge/admit

• MD critical care time

• Nurse time in direct care (acuity)

• Transport response time

• Total time for Radiology/CT/ Ultrasound

• Discharge to housekeeping entry

• Bed cleaning time

• Bed turnaround time

Automated Workflow: Milestone-Driven ED Notifications

Patient Flow Notifications Productivity Notifications

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• Wait time thresholds

• Ready for nurse

• Ready for doctor

• Time delay thresholds for clinician assessments, rechecks

• Time delay thresholds for procedures (lab, rad)

• Equipment par levels (pumps, wheelchairs, etc.)

• Decision to admit without written orders

• Transport notification upon dispo documentation

• Housekeeping notification upon dispo documentation

• Dwell time for holding patients

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Hand Hygiene Monitoring

• Monitor compliance o Soap-and-water

o Gel-based agents

• Multiple locationso Patient care areas

o Ancillary departments (pharmacy, laboratory, physical therapy, etc.)

o Food and Nutrition

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Hand Hygiene

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Compliance generally below 50% of the times caregivers

Entered or exited a patient’s room

Enter RoomEvent DetectedDOCUMENT

Exit RoomNo Event DetectedDOCUMENT & ALERT

Enter RoomNo Event DetectedDOCUMENT & ALERT

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RTLS-Facilitated Process Improvement Opportunities

• Elimination of “no-value-added” steps in the patient care process

• Standardization of “time-outs” before surgery

• Avoidance of the use of dirty infusion pumps

• Patient fall prevention

• Creation of communicable disease audit trails

• Pressure ulcer prevention

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… and in conclusion

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