presented by, matthew rusk, d.o. advisor: khalid qazi, m.d
TRANSCRIPT
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Presented by, Matthew Rusk, D.O.
Advisor: Khalid Qazi, M.D.
Employing Lean Flow to Streamline the Admission Process, Improve
Patient Satisfaction, Enhance Quality and Facilitate Cost Effective Care
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Objectives Introduce a concept that augments the
admission process by improving:Admission wait timesPatient satisfactionQualityCost Effective Care
Explain how change was implemented Discuss results Compare results to current literature
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Introduction—Lean Flow Business concept that is well known and
implemented daily by successful businesses
Often ignored in the healthcare industry
Gaining recognition in healthcare
Can make healthcare efficient and improve quality
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Introduction
ED overcrowding is associated with worse quality of care and service delivery quality (1);
Recent studies have shown clearly that wait time directly affects patient satisfaction (1-9);
Time to evaluation can also influence whether or not a patient is seen at all (1, 2, 10).
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Hypothesis
Utilizing lean flow will improve the admission process at Sisters of Charity Hospital by:
Decreasing the total admission process time
Improving patient satisfaction
Enhancing quality
Improving Cost Effective Care
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Methodology Implementation of Lean Flow
X32 Healthcare ‘Rapid Improvement 3-day Program’
○ CHS Staff;○ Four Residents;○ Lean Flow Education;○ ‘Front end’ Improvements;○ Little focus on admission process
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MethodologyApplied concepts to improve admission
process
Key Changes:
○ Admission Orders within 30 min;○ ED Holding Orders in certain situations;○ Earlier Bed Search;○ Easier access to order sets, charts and labels
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Methodology
Outcome measures
TimePatient SatisfactionQuality and SafetyCost Effective Care
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Methodology
Pre-interventionMarch 1 through October 31, 2008-2011
InterventionNovember 2011 – February 2012
Post-interventionMarch 1 through October 31, 2012
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Methodology-Time Intervals
Arrival to Departure (total admission time)Arrival to ED ProviderED Provider to Time Admitting Physician
Informed of admission (TAPI)TAPI to Admit OrderAdmit Order to Departure
Arrival ED Provider TAPI Admit Order Departure
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Methodology-Patient Satisfaction Questions:
Got help as soon as wantedQuiet around room at nightTreated with courtesy and respect by doctorsTreated with courtesy and respect by nursesRate HospitalWould recommend hospital to family
Answers 9 or 10 out of 10 defined as perfect score
8 or below defined as non-perfect (negative response)
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Methodology-Quality IndicatorsInpatient Specific ED Specific
Fall Rate
Core Measure ComplianceAMI, HF, PN, SCIP
RRT calls
Inpatient Mortality
Left Without Being Seen (LWBS)
ED Mortality
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Methodology—Cost Effective Care Average LOS
ED Volume
Total Admissions
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Results—Time Variables Summarized using means and standard
deviations.
An independent two-sample t-test using assumption of equal variances was used to test for differences in means.
A multiple regression model was used to test for differences adjusted for baseline variables (age, gender, race, Arr Method, and Bed Type).
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Time Interval Comparison
Time (minutes)
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(Decrease of 78.8 minutes [417.8 – 339 = 78.8])
Statistically Significant, P-value <.0001
Time (minutes)
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(Decrease of 35 minutes [168.5 – 133.5 = 35])
Time (minutes)
Statistically Significant, P-value <.0001
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(Decrease of 36.2 minutes [61.9 – 25.7 = 36.2])
Time (minutes)
Statistically Significant, P-value 0.0015
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Summary of Time Variables
Arrival to Departure (Total Admission Time) Decrease of 78.8 minutes 19% reduction in total admission time Most of our overall improvement during TAPI to Dep
TAPI to Departure Decrease of 71.2 minutes 31% reduction of this
TAPI to Admit Order Decrease of 36.2 minutes 58.5% reduction of this interval
Admit Order to Departure Decrease of 35 minutes 21% reduction of this interval
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Results—Patient Satisfaction
Summarized using frequencies and percentages.
A Pearson chi-square test was used to compare the proportion of satisfaction between pre and post.
Odds ratio and corresponding 95% confidence interval was calculated.
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Hospital Rating
Statistic DF Value ProbChi-Square 1 16.7623 <.0001
Chi-square test:
Type of Study Value 95% Confidence LimitsCase-Control (Odds Ratio)
1.7981 1.3561 2.3843Odds Ratio:
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Would Recommend Hospital To Family
Statistic DF Value ProbChi-Square 1 12.5009 0.0004Chi-square test:
Type of Study Value 95% Confidence LimitsCase-Control (Odds Ratio)
1.6931 1.2629 2.2698Odds Ratio:
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Treated With Courtesy and Respect By Doctors
Statistic DF Value ProbChi-Square 1 10.0276 0.0015Chi-square test:
Type of Study Value 95% Confidence LimitsCase-Control (Odds Ratio)
1.7113 1.2246 2.3914Odds Ratio:
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Treated With Courtesy and Respect By Nurses
Statistic DF Value ProbChi-Square 1 11.0264 0.0009Chi-square test:
Type of Study Value 95% Confidence LimitsCase-Control (Odds Ratio)
1.7703 1.2606 2.4861Odds Ratio:
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Patient Satisfaction Results All questions showed significant
improvement post-intervention.
Hospital Rating Scores improved to 70.2% (from 56.74%)
Recommend to Family Scores improved to 74.94% (from 63.85%)
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Results—Quality
Summarized using means and standard deviations
An independent two-sample t-test using assumption of equal variances was used to test for differences in means.
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Improved Inpatient Fall Rate
Falls significantly decreased (p-value < 0.0001)
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Improved ED Left Without Being Seen (LWBS)
38% reduction in LWBS
p-value is < 0.0001
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Improved Core Measure Compliance
Percentage of Perfect Care
Pre (%) Post (%)
P-value
AMI 91.41 100.00 0.0956
HF 84.35 100.00 <0.0001
PN 84.99 94.44 0.0293
SCIP 84.98 92.61 0.0006
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Decreased Number of Rapid Response Team Calls
p-value = < 0.001
Statistically Significant
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Mortality
Inpatient ED
p-value = 0.9053
No significant difference
p-value = 0.6264
No significant difference
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Quality SummaryInpatient Specific ED Specific
Improved Inpatient Fall Rate
Improved Core Measure ComplianceAMI, HF, PN, SCIP
Decreased RRT calls
No change in Inpatient Mortality
Improved Left Without Being Seen (LWBS)
No change in ED Mortality
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Results—Cost Effective Care
Summarized using means and standard deviations
An independent two-sample t-test using assumption of equal variances was used to test for differences in means.
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Improved Length of Stay
Average LOS decreased from 4.68 days to 4.36 days
(p-value < 0.0018)
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Increased ED Volume and Admissions
ED Volume increased 13.5%:Pre Volume avg = 23,624Post Volume = 26,799 (March-Oct)
Admissions Increased 3.5%:Pre Admission Avg = 4,002Post Admission = 4,141 (March-Oct)
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Cost Effective Care Summary
Improved Average Length of Stay
Increased ED Volume
Increased Admissions
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Discussion Yale-New Haven Hospital utilized lean and
reduced the time from decision to admit [TAPI] to transfer to floor [departure] by 33% (11)
Anecdotal recountWe had a 31% reduction of this time frame.
Lack of studies focus on admitted patients.
Lack of focus on admission times, affect of overall hospital rating after admission
Limited investigation on inpatient quality.
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Conclusion Our study fills void
○ focus on how lean affects the admission process and subsequent hospital stay.
Implementing Lean Flow at Sisters Hospital
Significantly Improved Admission TimesSignificantly Improved Patient SatisfactionSignificantly Enhanced QualityFacilitated Cost Effective Care
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Conclusion
Further improvements are possible Focus on specific time intervalsRe-evaluate processes
Lean Flow works and is an essential tool implement in healthcare.
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Acknowledgements Marylin Boehler, RN, Director of ED and Critical Care Julie Morgante, Quality Analyst, Quality & Patient Safety Department Terry Mashtare, PhD, UB Statistics Department Jingjing Yin, UB Statistics Department Entire Sisters Medical Records Department Abid Hussain, MBBS, IM Resident Sameer Waheed, MBBS, IM Resident Mohammad Tantray, MBBS, IM Resident Nancy Roder RN, BSN, Application Analyst, CHS Information
Technology X32 Healthcare—Lean Consulting Firm
Chuck Noon, PhD Brian Livingston, MD, MBA Jody Crane, MD, MBA Kim Adams, RN
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