a18 b18 presentation - ihiapp.ihi.org/facultydocuments/events/event-2206/presentation-7750/...•...

11/26/2012

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Customized ER Operational Strategiesfor Low Acuity Patients

Kirk Jensen, MD, MBA, FACEPJody Crane, MD, MBA, FACEP

Kevin Nolan, MStat, MA

Session A18/B18This presenter has nothing to

disclose

Participants will be able to:1.Describe strategies based on ER volume that can

be implemented in your ER to efficiently treat low acuity patient (i.e. Levels 4, 5 and some 3s).

2. Identify specific models and elements of design that could and should be applied in your ER.

The presenters have nothing to disclose

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Session Objectives

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Session Topics

1.Overview and setting context

2.Flow models for low acuity patients

3.Key elements of design for low acuity patients

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Why are we doing this?

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Timeliness of care has a strong correlation to patient satisfaction (1,2) with wait time to be treated by a physician having the most powerful association with satisfaction. (3)

1. Bursch B, Beezy J, Shaw R. Emergency department satisfaction:what matters most? Ann Emerg Med. 1993;22:586‐591.

2. Thompson DA, Yarnold PR, Williams DR, et al. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergencydepartment . Ann Emerg Med. 1996;28:657‐665.

3. Boudreaux ED, D’Autremont S, Wood K, et al. Predictors of emergency department patient satisfaction: stability over 17months.Acad Emerg Med. 2004;11:51‐58.

©Kirk B. Jensen, MD, MBA, FACEP

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Quality and Safety

0.90

2.74

4.16

012345

0‐30minutes

30‐60minutes

> 60minutes

Time to Physician

Average Claims / 25k patient visits

Source: Studer Group and CEP

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Effect of Working on “Low Acuity” Patients

ESI 2 ESI 3 ESI 4 ESI 5X

Error bars represent 95% Confidence Intervals for Mean LOS

3.0

2.75

2.50

2.25

LO

S (

in H

ours

)

Baseline 1 2 3 4 5 6 7 8 9

SCENARIO NUMBER

Why Designs for Low Acuity Patients Fail

• Unclear mission

• Entry criteria poorly defined

• Lack of dedicated (and committed) staff

• Capacity and demand mismatches

– Staff, space, supplies..

– Missing the ramp up

• Multiple handoffs

• Too sick patients

• Standardization failures

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“Mindless conformity and the thoughtful setting of standards should never be confused. What solid Standard Operating Procedures do is nip common problems in the bud, so that staff can focus instead on solving uncommon problems.”

Bill Marriott (of the Marriott hotel chain) as quoted by

Mark Graban in Lean Hospitals

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Standard Work

© Kirk B. Jensen, MD, MBA, FACEP

Standard Work

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The Importance of Standard WorkStandard Work/Documentation – Roles, Evidence‐Based Practices

• In low acuity patients, this may be more about process documentation than evidence‐based practices, making sure everyone understands their roles and work sequence

• Pain protocols and frequent flier pathways may be implemented and adhered to here

• Certain evidence‐based practices such as antibiotic practices and influenza pathways certainly have a role

© Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 201111

• Gold standard for LOS is 60 minutes or less, but hard to achieve.

• A median LOS for all low acuity patients (4,5, some 3’s) < 75min should be considered excellent

• The average is somewhere in the 90 minute to 120 minute range.

• As far as ideal throughput time, controlling for quality and safety, the shorter the better from the patient's perspective.

Design Targets for Low Acuity Patients

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The EDBA Annual ED Data Survey

2011 Results for 830 EDs Hi CPT Under Admit % Transfer EMS EMS Median MLOS Treat MLOS LBTC Door EKG

seeing 29.6m pts Acuity age 18 % Arrival Arrival Admit LOS & Release Admit to Doc per 100

Over 100K 66% 20.2% 21.8% 0.9% 23% 42% 214 182 356 2.3% 31 30

80 to 100K 71% 18.4% 20.9% 1.1% 21% 44% 218 187 362 3.4% 38 25

60 to 80K 66% 18.2% 20.8% 1.2% 19% 44% 205 174 337 2.8% 35 31

40 to 60K 65% 19.5% 19.1% 1.4% 18% 43% 186 156 303 2.3% 33 28

20 to 40K 63% 20.2% 17.1% 1.8% 16% 41% 160 134 261 1.7% 28 26

Under 20K 55% 23.7% 12.7% 2.7% 12% 39% 139 115 227 1.4% 23 20

Pediatric 48% 99.0% 11.4% 0.6% 8% 33% 147 132 270 1.4% 31 4

Adult, Specialty 71% 2.7% 25.5% 1.1% 23% 48% 240 204 346 3.2% 40 34

Urgent Care,Freestanding 41% 23.6% 4.2% 3.4% 7% 31% 100 97 240 1.0% 22 12

2011 Data from the Emergency Department Benchmarking Association (EDBA)

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General Principles

• The front door and your front end processes drive flow.

• Triage is a process, not a place. • Get the patient and the doctor together

as quickly and efficiently as possible.• “Fast track” is a verb, not a noun.• Keep your vertical patients vertical and

in motion.• For horizontal patients, real estate

matters. For vertical patients, speed matters.

• We want to be fast at fast things and slow at slow things.

Kirk Jensen/Thom Mayer/ Jody Crane

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Front End Patient Flow: A Portfolio of Options

• Advanced Triage Orders/Treatment Protocols

• Fast‐Tracking Low‐Acuity Patients:

– Super‐Track (ESI 5’s + simple 4’s)

– Fast‐Track (ESI 5’s, 4’s, and simple 3’s)

• Clinician in Triage – Rapid Medical Evaluation (RME)

– Midlevel Provider in Triage

– MD in Triage

– Intake Team/Team Triage (multi‐disciplinary assessment and treatment team)

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Front End Patient Flow: A Portfolio of Options

• Advanced Triage Orders/Treatment Protocols

• Fast‐Tracking Low‐Acuity Patients:

– Super‐Track (ESI 5’s + simple 4’s)

– Fast‐Track (ESI 5’s, 4’s, and simple 3’s)

• Clinician in Triage – Rapid Medical Evaluation (RME)

– Midlevel Provider in Triage

– MD in Triage

– Intake Team/Team Triage (multi‐disciplinary assessment and treatment team)

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A Portfolio of Options available to be set up as patient volume and demand either requires it or can justify it . The front‐end flow tactics(s) are selectively and scientifically deployed at certain hours of the day and days of the week based upon your demand‐ capacity modeling of incoming patient flow.

Models for Low Acuity Patients

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Super Track

A Fast Track located in or near triage for the purpose of promptly treating patients who require very low resource utilization

Treatment Room 1

Treatment Room 2

Procedure Chair Results

Waiting

1 Doc/MLP1 RN/LPN

1 Tech

Entrance/Exit


Super Track Volume Bands

© 2011, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.

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Rapid Medical Evaluation (RME)

• Midlevel Provider in Triage

• MD in Triage

• Intake Team (multi‐disciplinary assessment

and treatment team)

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1. Keep area open, visible to all

2. Keep patients upright3. Keep all equipment

/manpower mobile4. Each station has to be

user friendly

One STOP shopping

© Kirk B. Jensen, MD, MBA, FACEP 22

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Intake System

Team of providers that promptly assess, treat, and discharge primarily level 3 patients

2 Providers (Doc/MLP),2 RN/LPN,1 Paramedic2 Scribes, 1PSR/HUC

Quick Look Quick Reg

Quick Triage

TreatmentArea

5 Rooms

Results Waiting

Intake Volume Bands

© 2011, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 24

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General Operational Strategies for Low Acuity Patients by Volume

20,000 • No triage, Immediate bedding, bedside registration for all• No Segmentation – Clear signals to identify low acuity patients• Results waiting

40,000• Quick Look Triage to segment, Quick/Bedside Registration for all• For ERs with low acuity/low admit: Super Track (9a‐11p) with 1‐2

MLP with committed resources for lab/rad• For ERs with high acuity/high admit: Intake Team (9a‐11p) with

1 doc, 1 MLP with committed resources for lab/rad• Results waiting

60,000 • Quick Look Triage to segment, Quick/Bedside Registration for all• Super Track (8a‐1a), MD/MLP Intake Team (9a‐11p)• Results waiting

25© Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 2011

From Models and Strategies to DESIGN:Key Elements of a Design for Low Acuity ER Patients

1. Profile of patient demand by hour of the day2. Average service times required to match demand 3. System for patient segmentation 4. Distinct processes for low acuity patients 5. Right staffing mix6. Contingencies for large fluctuations in demand or capacity

Matching Your Demand:26© Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 2011

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• You should know your arrivals by hour of day

• Busy and slow days

• Broken down by – Chief complaint

– ESI Level

– Ancillary Utilization

1. Profile of low acuity patient demand by hour of the day


2. Average Low Acuity Service Capacity (bed, doc, nurse) required to match demand

This can be expressed in 1) patients per hour or 2) in terms of how much time you have and how much time it takes.

1. If 3 low acuity patients are coming through per hour, and your service rate is 2.5 patients per hour, then you have some work to do.

2. Similarly, if 3 low acuity patients are coming through per hour, then you have 20 minutes per patient. If it takes you 24 minutes, you must improve your process


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Scientific Management: Matching Capacity to Demand‐Arrivals vs. Staffing (MD and

MLP coverage)

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Demand vs. CapacityMinorCare

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Demand vs. Revised CapacityMinorCare - Heavy Days

Average Demand Modeled Demand Capacity

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Matching Capacity to Demand‐Arrivals vs. StaffingEfficiency and Effectiveness

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Nursing Demand

Efficient AllocationExample: 96 Nursing Hours

Demand Efficient Allocation

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Nursing Demand

Inefficient AllocationExample: 96 Nursing Hours

Demand Inefficient Allocation

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Getting the patient to the right place, at the right time, with the right treatment

Patient Enters

Immediate bedding in

back

Streamlined Care

ST/FT/TT/RW

Sick

Patient Sorted

Not Sick

Doctor To see Now

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3. System for Patient Segmentation


• ESI – Based– 4’s, 5’s, and criteria

based level 3’s

– Age criteria

– CC criteria

• Other Triage Scale– CTAS

– Manchester

– ATS (Australia)

• Historical Resource Utilization

© Kirk Jensen, MD, MBA and Jody Crane, MD, MBA, 2011 32

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Triage

Brief RN Assessment:ESI Evaluation / Evaluation of Acuity

High AcuityPathway

ESI Levels 1 + 2

Moderate AcuityPathway

Most ESI Level 3sLow Acuity

PathwayESI Levels 5, 4,

+ some 3s

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NOTE: If your processes are the same, segmentation will actually hurt your overall system performance due to anti‐pooling

© 2012, Crane, Noon, Leitner

15‐20%Super Track

ESI 4‐5

20‐30%Main EDESI 1‐3

50‐60%Intake/PODs

ESI 3

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Emergency Streaming: an exampleRN

3. System for Patient Segmentation/ distinct area in ED to treat specific patient

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Standardize! Who is Appropriate for Low Acuity?

35© 2012, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.

4. Distinct Processes for Low Acuity Patients

All processes should be designed with “Flow” in mind. Consider:

‐Medications‐Radiology and lab services‐Point of use supplies‐Point of care testing‐Visual signals‐Results waiting


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4. Distinct Processes: Medications that can be given in intake

Standardize!

– Stick with PO meds primarily

– PO pain meds OK

– Nebs OK

– IM injections OK, but stick with non‐narcotics

– No IV’s unless the patient is heading towards a treatment area, no IVF

© 2011, Jody Crane, MD, MBA 37

4. Distinct Processes: Radiology and Lab Services for the Front End and Triage

• Lab and radiology should have easy, reliable access to patients. They should be located near triage and fast tracking area if possible to promote patient flow.

• Phlebotomy should be available at triage

• Transporters are underutilized, underappreciated, and should be employed


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Super Track ‐ Ancillaries


4. Distinct Processes: Point of Use Supplies

• Should have a system in place such that supplies are readily available

• Commonly used supplies should be close to the point of use, quickly accessible –b lood tubes, medications fluids, CT supplies(contrast) pelvic exam equipment

• Can be set-up and charged outside of the patient care window

• Can be determined by chief complaints of patients targeted for FT


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• I‐Stat ‐ 3 min– (H/H, Chem 8, CKMB,Trop I, BNP, PT/INR, ABG, Lactate )

Chempaq

POC CBC with diff!

Biosite – 10 min

Myoglobin, Ck‐MB, Trop I, BNP, D‐dimer

Clinitech ‐ 2 min

U/A, UPT

Piccolo – 12 min

BMP, CMP,Electrolytes

Rapid strep, mono, influenza…

41© 2012, Jody Crane, MD, MBA

4. Distinct Processes: Point of Care Testing


Signals indicating the patient status in the room, signals on the floor to indicate the path patient should take for lab or x‐ray

4. Distinct Processes: Visual Signals

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Visual SignalsThe goal of visual signals/visual controls is to make performance, waste, problems, and abnormal conditions readily apparent to employees and managers

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4. Distinct Processes: Results Waiting

• Should be available close to triage

• Used to buffer long Rad/lab TAT without consuming bed resources

• Need an “eye” on this area

• Should be designed with customer service as #1 thought


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Standardize!• Who is eligible for Results Waiting? There are many variation depending on how elaborate the RW area is– Ambulatory

– Should need very few interventions

– Very low risk

– No etoh, homeless, etc

• Can get more elaborate in the right settings:– IV narcotics after observation period

– IV abx after observation period

© 2011, Jody Crane, MD, MBA45

Results Waiting

• Can be internal or external– External – usually back out to the ED waiting room

• Advantages – limitless capacity, already triage nurse eye on area

• Disadvantages – patients can wander, poor visibility, patient satisfaction

– Internal• Advantages – patients feel they are in process, dedicated supervision

• Disadvantages – space limited

• Should be entertaining and comfortable


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If an Airport can do it…


If an Airplane can do it…


Picture compliments of Jim Lennon, Arch

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• For most low acuity patient populations, midlevel staffing is preferred

– Low cost

– Right skill mix

– Little risk of rework or physician intervention

• Exceptions would be

– If your docs have to see every midlevel patient prior to discharge

– If you do not have sufficient volume of low acuity patients to justify a segmented stream

– Volume and acuity justify the full deployment of a physician upfront

5. The right staffing mix/skill mix/training


6. Contingencies for large fluctuations in demand or capacity

• For low acuity areas, you want high utilization; therefore, there is not much room for surge.

• EDs should be designed with progressively more capacity as the acuity level increases

– As such, low acuity should be able to “spill over” into mid acuity areas and mid acuity to high as a general rule

Low Acuity

Mid Acuity

High Acuity


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In Summary:Improving Flow for Low Acuity ER Patients

• Select models and strategies based on volume/demand

• Focus on Design 1. Profile of patient demand by hour of the day2. Average service times required to match demand 3. System for patient segmentation 4. Distinct process for low acuity patients 5. Right staffing mix6. Contingencies for large fluctuations in demand or capacity

• Standardize!

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Questions to Consider on Your Way Home…

• If you could do three things to either improve your Emergency Department, or improve your ability to improve your Emergency Department, what would they be…

• How can your ED, your Team and your Hospital best work together to …

• What are your next action steps…

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Resources, References, and Benchmarking

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Improving Patient Flow In the Emergency Department

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Kirk Jensen/Jody Crane

Hardwiring FlowSystems and Processes for Seamless Patient Care

Thom Mayer, MD, FACEP, FAAP Kirk Jensen, MD, MBA, FACEP

Why patient flow helps organizations maximize the “Three Es”: Efficiency, Effectiveness, and ExecutionHow to implement a proven methodology for improving patient flowWhy it’s important to engage physicians in the flow process (and how to do so)How to apply the principles of better patient flow to emergency departments, inpatient experiences, and surgical processes

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The Definitive Guide to Emergency Department Operational Improvement

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Jody Crane MD MBA (Author), Chuck Noon PHD (Author)

Leadership for Smooth Patient Flow:Improved Outcomes, Improved Service, Improved Bottom Line

Kirk B. Jensen, MD, FACEP Thom A. Mayer, MD, FACEP, FAAP Shari J. Welch, MD, FACEP Carol Haraden, PhD, FACEP

The heart of the book focuses on the practical information andleadership techniques you can use to foster change and remove thebarriers to smooth patient flow.

You will learn how to: Break down departmental silos and build amultidisciplinary patient flow team Use metrics and benchmarking datato evaluate your organization and set goals Create and implement areward system to initiate and sustain good patient flow behaviorsImprove patient flow through the emergency department—the mainpoint of entry into your organization The book also explores whathealthcare institutions can learn from other service organizationsincluding Disney, Ritz-Carlton, and Starbucks. It discusses how toadapt their successful demand management and customer servicetechniques to the healthcare environment.

“This book marks a milestone in the ability to explain and exploreflow as a central, improvable property of healthcare systems. Theauthors are masters of both theory and application, and theyspeak from real experiences bravely met.”

Donald M. Berwick, MDPresident and CEO

Institute for Healthcare Improvement (from the foreword)

ACHE + Institute for Healthcare Improvement

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The Hospital Executive’s Guide to Emergency Department Management

Kirk B. Jensen, MD, FACEPDaniel G. Kirkpatrick, MHA, FACHE

Introduction: Why the ED Matters 1. A Design for Operational Excellence 2. Leadership3. Fielding Your Best Team 4. Improving Patient Flow in the Emergency Department5. Customer Service: Ensuring Patient Satisfaction 6. ED Change Initiatives: Getting Things Done7. ED Change initiatives‐Managing Change8. Patient Safety and Risk Reduction9. The Role and Necessity of the Dashboard10. How the ED Is a Business11. Billing, Coding, and Collections12. Physician Compensation Models‐‐Productivity‐Based

Systems

HcPro ISBN: 978‐1‐60146‐742‐3

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The Improvement Guide and Rapid-Cycle Testing

Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP.

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition).

San Francisco: Jossey‐Bass Publishers; 2009.

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References

• Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): 1113‐1118.

• Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C. 2000.

• Christensen, C, J Grossman, and J Hwang. The Innovator's Prescription: A Disruptive Solution for Health Care. 2009.

• Full Capacity Protocol. www.viccellio.com/overcrowding.htm

• Goldratt, E. The Goal. Great Barrington, MA: North River Press, 1986.

• Holland, L., L. Smith, et al. 2005. “Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay.” Am J Clin Pathol 125 (5): 672‐674.

• Husk, G., and D. Waxman. 2004. “Using Data from Hospital Information Systems to Improve Emergency Department Care.” SAEM 11(11): 1237-1244.

• Jensen, Kirk. “Expert Consult: Interview with Kirk Jensen.” ED Overcrowding Solutions Premier Issue.Overcrowdingsolutions.com. 2011.

• Kelley, M.A. “The Hospitalist: A New Medical Specialty.” Ann Intern Med. 1999; 130:373-375.

• Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org).

• Wilson, M., and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments. Urgent Matters White Paper. September, 2004.

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Benchmarking Resources

Where to find dataYour neighbors

• Call and/or visit

ACEP• http://www.acep.org

Premier• www.premier.com

VHA• www.vha.com

ED Benchmarking Alliance• www.edbenchmarking.org

UHC• www.uhc.org

Be sure to compare hospitals with similar acuity and similar volume…

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