intelligent bed-flow and return on investment: intelliflow...intelliflow, development and rapid...

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Intelligent Bed-Flow and Return on Investment: IntelliflowSession #295, March 9, 2018Brian Collins, Director of Decision Support, Lawrence General Hospital

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Brian Collins has no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda• Learning Objectives• Document the Need• Build a Business Case and Plan• Intelliflow, Development and Rapid Cycle Improvement• Outcomes and Return on Investment (ROI)• Continuous Improvement • Questions

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Learning Objectives• Recognize and quantify the need for healthcare

information management systems (HIMS)• Formulate a business case and plan to develop

and deliver identified HIMS• Discuss the outcomes of HIMS

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Lawrence General Hospital (LGH)Lawrence General Hospital is a disproportionate share hospital in the Merrimack Valley of Massachusetts, 30-minutes north of Boston MA.

189 Licensed Inpatient Beds• Including 120 adult acute and 19 critical care; no inpatient psychiatric unit.

68,000 patient encounters in the Emergency Department (ED)• Approximately 15% admitted to inpatient and 4% to observation (19% admitted).• Represents approximately 85% of LGH total inpatients and 95% of observations.

41 ED exam rooms• Typically, 25-50% of the 41 exam rooms are occupied by inpatient and observation

admissions awaiting beds on LGH units.

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Document the NeedThe Patient Progression Steering Committee (Hospital Flow per Joint Commission standards) evaluated interventions on a PICK chart: Possible, Implement, Challenge, Kill.

Catalogued every existing, planned, or pitched idea regarding patient flow.

Gathered every existing flow measure.

Pick, support, and execute three high impact projects.

Impact

Effort (support needed)

Implement Challenge

Possible Kill

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Document the NeedFocus on high impact projects already underway, needing more support:

• Multi-disciplinary Bedside Rounds already underway with Hospitalists and Nursing for Communication related to patient experience scores.

• Chest Pain Observation Unit (CPOU) already underway with Chest Pain Center of Excellence accreditation.

• Environmental Services (EVS) was researching electronic bed management systems.

Current pagers provided no information management.

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Document the Need for HIMS• EVS needs a bed management system.

– Pre-2011: Home-grown electronic bed-board system built-off legacy admission, discharge, transfer (ADT) system.

– 2011: EMR rolled-out at LGH with integrated ADT.• Electronic bed-board not included; home-grown no longer interfaced.

– 2012-2014 started and stopped process to acquire system multiple times.– FY15 goal: Budget approval for $110k to acquire new bed

management system and implement for start of FY16.

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Build a Business Case Conducted a tracer over 3-weeks on adult acute units (October 2014).

Four Adult Medical/Surgical Units, 128 total beds (at that time).Traced active ‘Discharge Home’ and ‘Discharge Home with Services’ orders from 8A-5P, Monday-Friday; walked by room every 15-minutes. Traced 58 cases on eight days over a three week period.Bed-vacated time confirmed for 42 cases.

Significant slack in the process indicated an opportunity.

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Build a Business Case Tracer: Discharge Order to Patient Vacating the Bed to Electronic Update

Discharge OrderBetween 10-11A

Bed Vacated by PatientReported accurately 25%

Discharged in EMR/ADT

Between 2-4P 90-150 minutes 30-105 Minutes

Electronic Update is trigger for Environmental Services

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Build a Business Case Significant slack in the process indicated opportunity:• Current state led to 10 to 12+ requests to clean beds between 3-4P.

Four EVS staff on third-shift would clean the first four beds within 30-minutes;Not start the next four beds for another 30-minutes;

And not start the next 2 to 4+ beds for another 60-90 minutes, plus any new requests.

Need for visual queues and process.

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Build a Business Case and PlanEnvironmental Services measures of success:• Ability Track Room Status: Clean, dirty, precaution, other restrictions; pending discharge.• Report turnover times, performance and ensure proper EVS staffing levels.• Reduce time lags in the bed turnover process.• Reduce STAT cleaning requests by proactively prioritizing, assigning and cleaning rooms.

Patient Flow measures of success:• Increase the # inpatients discharged home before 3P to meet demand.

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Build a Business Case and PlanUnderstanding the impact on hospital wide patient flow:

ED volume first peaks at 11A

Admission orders beginning in quantity at 2P

63% of Inpatients Discharged after 3P (2014 Current State)

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Intelliflow, Development and Rapid Cycle Improvement• Multi-Disciplinary Team:

Environmental Services (EVS); Registration, Admitting; Patient Care Services (Nursing); Information Services; Nursing Supervisors; Administration.

• October 2014: Weekly meetings started to support the tracer exercise.– Nov-Feb: Vendor search, demonstrations, and vetting process.

• Quickly realized: Regardless of vendor, IS had to be involved to integrate; this kept the door open for in-house development.

December 2014: ‘Pending Order’ reporting process run manually x5 day.• February 2015: Decision to build in-house based-on cost and plan.

Visual queue: Orange Car = Active Discharge Orders.

Real-time feed from EMR includes order information.

Discharge is completed in Intelliflow, which updates EMR

and triggers EVS process.

Intelliflow: Nursing Unit View

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Intelliflow: Environmental Services turnaround process• Housekeepers sign for an Apple iPod at the beginning of every shift. • Discharged or transferred patients trigger a request to EVS.

– STAT rooms listed on device by priority level as requested by Nursing.– Pre-caution rooms are identified by a “Bug” next to Rm. #.

• To Start, click “My Assignments” Select room then “Start.”

Then “Complete” once done.

Intelliflow: User roles determine screens.

Allowing Nursing supervisors to change priority of bed cleaning requests.

Enabling EVS to manage in-process and outstanding requests.

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House-wide dashboard with Physical and Staffed Beds and Current Census (below).And Pending Disposition screen with active Discharge, Admit, and Transfer Orders (next slide).

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Pending Disposition screen with active Discharge, Admit, and Transfer Orders.

Length of time since Discharge

Order was started and

Discharge Disposition

(Home, SNF, etc.)

Pending ED admissions with wait time and unit

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December 2014: ‘Pending Order’ reporting process.July 2015: ‘Intelliflow’ pilot launch on largest unit (40 beds).September 2015: House-wide go-live.

Intelliflow, Development and Rapid Cycle Improvement

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Change Management:“It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones.”


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Change Management:“It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones.” Niccolò Machiavelli, ‘The Prince’, 1532


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+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%

Mean Rate(center line)

36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge

% Discharges Home and Home with Services prior to 3PM by week 13-week average % of patients discharged prior to 3PM by week, 1/1/2012-9/30/2017

+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%


36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge


63% Inpatients Discharged Home AFTER 3PBy week (Sun-Sat), 155 weeks, Jan 2012-Dec 2014.

Average % Discharged before 3P = 36.9% (Mean Rate, Center Line)

95% of weeks (8 of 155) falling between 25-48%

discharged before 3P (+/- 2 standard deviations)

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+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%


36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge


+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%


36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge


July 2015: Pilot launch on largest unit (40 beds)December 2014New ‘Pending

Order’ process September 2015: House-wide go-live.

Roll-out, Adoption, and Communicate the Outcomes…Change ManagementContinuous Improvement

+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%


36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge

% Discharges Home and Home with Services prior to 3PM by week 13-week average % of patients discharged prior to 3PM by week, 1/1/2012-9/30/2017 % Inpatient

Discharged Home before 3P went from 36.9% in 155 weeks leading up to first

intervention

To 55.1% in the 106 weeks since

house-wide go live in September 2015

50% increase

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ROI: +6% Inpatient Discharges among originally traced population+309 Inpatient Discharges Home on Adult Acute units FY15-16

+$2.5M net revenue assuming $8k per adult acute discharge home

Inpatient Discharges

Home on Adult Acute Units

and % before 3P by FY

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ROI: +4% Total LGH Inpatient Discharges FY15-17 with higher Case Mix IndexPublished article: Healthcare Financial Management; Jul 1, 2017

‘Raising CMI Through a Multidisciplinary Approach in the Community Hospital Setting’By Brian Collins, George Kondylis MD, Schawan Kunupakaphun, and Pracha P. Eamranond MD

Total Inpatient

Discharges and %

before 3P by FY

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Among other factors, fewer transfers from ED

to other acute care hospitals has catapulted

LGH Medicare CMI from 1.29-1.32 (FY13-15) to 1.39

and 1.36 in FY16-17 respectively.

Estimated financial impact over $1M.

Transfers from ED to other acute care hospitals

ROI: +4% Total LGH Inpatient Discharges FY15-17 with higher Case Mix IndexPublished article: Healthcare Financial Management; Jul 1, 2017

‘Raising CMI Through a Multidisciplinary Approach in the Community Hospital Setting’

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+2 St.Dev.48.2%

+1 St.Dev.42.5%

-1 St.Dev.31.2%

-2 St.Dev.25.6%


36.9%

+3 St.Dev.53.8%

+4 St.Dev.59.4%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

1/7/121/28/122/18/123/10/123/31/124/21/125/12/126/2/126/23/127/14/128/4/128/25/129/15/1210/6/1210/27/1211/17/1212/8/1212/29/121/19/132/9/133/2/133/23/134/13/135/4/135/25/136/15/137/6/137/27/138/17/139/7/139/28/1310/19/1311/9/1311/30/1312/21/131/11/142/1/142/22/143/15/144/5/144/26/145/17/146/7/146/28/147/19/148/9/148/30/149/20/1410/11/1411/1/1411/22/1412/13/141/3/151/24/152/14/153/7/153/28/154/18/155/9/155/30/156/20/157/11/158/1/158/22/159/12/1510/3/1510/24/1511/14/1512/5/1512/26/151/16/162/6/162/27/163/19/164/9/164/30/165/21/166/11/167/2/167/23/168/13/169/3/169/24/1610/15/1611/5/1611/26/1612/17/161/7/171/28/172/18/173/11/174/1/174/22/175/13/176/3/176/24/177/15/178/5/178/26/179/16/17

Week of Discharge

% Discharges Home and Home with Services prior to 3PM by week 13-week average % of patients discharged prior to 3PM by week, 1/1/2012-9/30/2017 13 of 52 weeks in

FY17 had more than 60% Discharges before 3P

Versus 13 weeks in FY13 with less than 30% Discharges before 3P 32

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Continuous Improvement

• +60% Inpatients discharged home before 3P in 25% of FY17 (13 of 52 weeks) versus 25% of weeks in FY14 below 30% before 3P. (previous slide)

• Multiple other projects have greatly impacted patient flow, inpatient discharges before 3P, and inpatient and observation volume since the roll-out of Intelliflow.

• Earlier discharge orders and initiatives.• Multidisciplinary rounds continue to evolve and are driving

development in Intelliflow and other processes and tools.• Projects over periods of time on specific units produce demonstrable

results, reaching +80% discharged before 3P and driving house-wide rates upward.

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Conclusion

• Identified the need for healthcare information management system (HIMS)

• Built a business case and plan to develop HIMS• Delivered new HIMS and managed change• Communicated the outcomes• Returned on the Investment (+3.5M returned on 110k investment)• Continue to improve

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Questions• Brian Collins, Director of Decision Support

– [email protected]– 978.946.8318
mailto:[email protected]

intelligent bed-flow and return on investment: intelliflow...intelliflow, development and rapid...

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