Hospital and Financial Performance:Improving throughput, flow, and efficiency of care for acutely ill hospitalized patients

J. Christopher Farmer

Discussion Points

‣ Framing the issues

‣ Where are we now?

‣ What works and what does not?

‣ How do we identify opportunities for gaining efficiency?

‣ Methods to improve flow and throughput

‣ Measuring impact

In the hospital:Where are the biggest bottlenecks?

EmergencyDepartment

ICU

StepDownUnit

WARD

An average “bottleneck” day?

‣ All ICU beds are “full” with medical patients currently in the CVICU, SICU, and CCU

‣ The intermediate care unit is “full”

‣ Three scheduled CV surgical cases today with one bed opening “later”

‣ Two patients in the ED require MICU admission (beds)

‣ One neuro-ICU patient transfer request pending (acute stroke) from the region

‣ Should we go “on diversion” with EMS?

A day in the life of critical care at a busy hospital…

CRITICAL CARE RESOURCE DEMAND

REGIONALREFERRALS

EMERGENCYDEPARTMENT

“IN-HOUSE”EMERGENCIES

OPERATINGROOM SERVICES

MICU

SICU NeuroICU

CCU

CV-ICU INTERMED.CARE UNIT

TELEM..

1. LIMITED AVAILABILITY RESOURCES

2. MANY DECISION-MAKERS

3. VARIABLE DECISION CRITERIA APPLIED

WARDS

POST-PROCEDUREMONITORING

LOCALREFERRALS

“chronic crisis mode”…a global affliction

Fixing these problems every day?The turning radius of a cruise ship

A critical care reality check…

‣ Most hospitals have enough ICU and acute beds to meet current demand almost every day…

‣ EMS diversion is a widespread problem

‣REMEMBER: diversion is not a demand management tool…it is an excuse!

‣Diversion = hospital + physician lost revenue (≈ 37,000 USD/pt.)

‣ No data + no physician engagement = CHAOS

‣ So, hospitals build more ICU beds without changing current practices (a culture change)

‣This results in little to no net improvement in these problems!

In today’s world--where should tertiary hospitals be going?

Development of a hospital service (product) line that meets the internal and external demands of critical care and acute medicine

‣ Personnel

‣ Quality

‣ On-site physician coverage 24/7

‣ Data management

‣ Demand management

‣ Education

‣ Fiscal performance

‣ Longitudinal care

What does an acute medicine service line look like?

It links the emergency medicine, the critical care, and hospital medicine physicians into a real or virtual group

This also should include nurses and inpatient pharmacists who work in the ICU, step down unit, and involved wards

It defines protocols and procedures for treating common serious illness that are followed by all team members

Examples include management of sepsis, pneumonia prevention, sedation-delirium management, prevention of catheter infections

It should include hospital management support in order to track cost, length of stay, quality and safety, etc.

Maximizing hospital throughput

Learn about the “A” team: “prevention” is better than “predicaments”

‣ Assessment of initial/ongoing need for ICU care [APPROPRIATENESS]

‣ Accuracy of initial/subsequent patient placement [EFFICIENCY]

‣ Accurate and timely decision-making [EFFICIENCY]

‣ Availability of reliable “downstream” resources (intermediate care, telemetry, SNF, LTAC, etc.) [EFFICIENCY]

‣ Assessment and reassessment of physiological status and care requirements [DEMAND MANAGEMENT]

‣ Aggressive development/implementation of care “protocolization” [QUALITY, OUTLIER MANAGEMENT]

‣ Attending physician patient management is on-site (intensivist and hospitalist) [QUALITY, OUTLIER MANAGEMENT]

‣ APN’s and other ancillary personnel (data management, pharmacy, RT, etc.) [EFFICIENCY, DEMAND MANAGEMENT, QUALITY]

‣ Availability of important clinical and administrative data for “real-time” decision-making (severity of illness, other clinical, UR, cost) [DEMAND MANAGEMENT, QUALITY, OUTLIER MANAGEMENT]

Planning patient “flow”...From the front door to the back door

ED orOUTSIDE

REFERRALICU

ADMISSIONPCU

TRANSFERWARD

TRANSFERHOSPITALDISMISSAL

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Admitting physician

access

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Transfer physician

access

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Transfer physician

access

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Transfer physician

access

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Transfer physician

access

ACUITY OF ILLNESS

Common themes emerge!

‣ Multiple calls‣ Transfer delays‣ Bed availability‣ Admitting physician

access 1. Dependence on individuals, not processes

2. Communications not protocolized

3. Hand-offs not “choreographed”

4. Delayed decision making (dependent on individuals)

5. Bed management: reacting to requests versus anticipating needs

6. Not advancing care plans 24/7!

Evolving from demand management versus demand forecasting

PATIENT IN THE ED

NEEDS AN ICU BED

MEDICAL ICU

Do you have a bed?

6 hour delay

STEP-DOWNUNIT

1 day delay

WARD

1 day delay

NURSINGHOME

3 day delay

Net impact:

‣ 5.25 days added to hospital LOS

‣ Additional hospital costs

‣ LOS increases X annual patient load = increased personnel requirement

‣ Increased ICU and Step-down bed requirements

‣ Decreased staff satisfaction (increased frustration)

‣ Quality of care?

No, call back in2-4 hours

No, call back in2-4 hours

No, call back in2-4 hours

No, call back in2-4 hours

Evolving from demand management versus demand forecasting

0600-1200 1200-1800

1800-24002400-0600

0600-1200 1200-1800

1800-24002400-0600

0600-1200 1200-1800

1800-24002400-0600

0600-1200 1200-1800

1800-24002400-0600

ED MICU Ward

Historical number of admissions during each 6 hour time frame for each day of the week

Wednesday,3 admissions

Wednesday,1 admissions

Step-downUnit

Evolving from demand management versus demand forecasting

ICUPATIENT

READYTO GO

READYTO GOWHEN...

NOT READYTO GO

0600 1800

MOVE NOW ADVANCE THE CARE PLANRE-EVALUATE TOMORROW

Adequate Intermediate Care Unit resources:Not enough = Continuum of care issues…

CRITICALCAREUNITS

FRONT DOORBACK

DOOR

INTERMEDIATECAREUNIT

‣ Bandwidth‣ Care protocols‣ Triage guidelines‣ ICU:PCU bed ratios‣ Provider non-compliance‣ Patient volume-induced inefficiencies

Defining priorities…

An acute medicine development project…You need a “team” that will:

‣ Address ICU throughput and resource utilization issues

‣ Address continuum of care issues

‣ Quantify additional critical care physician and non-physician recruitment needs (staffing model including coverage expectations)

‣ Address critical care quality and patient safety program needs

‣ Address the role of residents in the critical care units

‣ Develop and advance ICU team functionality (doctors, nurses, allied health professionals)

think big, start small, go fast…

Address ICU throughput and resource utilization issues

In order to improve access to ICU beds

‣ patients must be accurately triaged and acuity matched to the correct unit

‣ decision-making criteria (admission & discharge, etc.) must be consistent and predictable in all units

‣ there must be sufficient numbers of intermediate care beds (also with disciplined criteria for resource utilization)

‣ a designated physician(s) must oversee processes 1-3 in order to ensure consistency and compliance

‣ Care protocols and bundles should be used in order to optimize efficiency

Improving throughput: the bottom line…

‣ Our challenge isn’t knowing what to do to avoid “logjams,” most have that reasonably defined…it’s getting it done (change management)

‣ That’s OK…change management is difficult for every organization

‣ We need to our spend time defining priorities along with the specific strategies to get these implemented!

‣ No accountability = no durable change

Intermediate Care Unit

Intermediate Care Unit = Progressive Care Unit

‣ Should be multi-disciplinary or have more than one unit

‣ Need more beds relative to total number of ICU beds!

‣ NO POACHING = NO ICU PATIENTS IN THE PCU

‣ On-site supervision: ICU teams versus ward teams

(recommend considering a hospitalist service)

‣ Need better (and sooner) hand-offs from the ICUs

‣ Palliative care services

So what do we do?1. Review historical data: who are the

patients, where are they coming from, what is wrong with them, what do they need from us? (but don’t linger and over-analyze!)

2. Review the “pipeline” from the front door to the back door…outline bottlenecks, targets, and then define specific implementation measures (we have a lot of what we need already “on paper”)

3. Create “Top 10” barrier list and define specific “counter measures”

4. Create a plan of action…2009, 2010, 2012, 2014 (as part of the 1, 3, and 5 year strategic plans)

Historical data reviewPerformance review

‣ Top 5-10 admission diagnoses to the ICU’s (stratified by unit)

‣ Which (insurance) payment codes are linked to these diagnoses?

‣ LOS (hospital + ICU) for each of these payment codes

‣ Financial performance by payment code (which of these offer the largest [positive and negative] margins? What is our market share for these activities?

‣ Are there other (not top 10) payment code categories with small numbers of patients but strongly positive margins?

Yes, the details are important...

Protocolized (standardized) management improves clinical outcomes (published data)

‣Sepsis

‣Acute myocardial infarction

‣Central line insertion and catheter site maintenance

‣Ventilator use strategies in ARDS

‣Ventilator bundle

‣Glucose control

‣Sedation and delirium management

‣Surgical site wound care

‣Daily goals sheet (communications tool)

‣Communications tools for assessment and transfer to lower levels of care

‣Rapid response teams

‣Multidisciplinary, team-based rounds

‣Use of remote ICU virtual presence monitoring by intensivists and critical care nurses

‣On-site intensivist program

‣On-site hospitalist program

‣Adverse drug event prevention program

TEAM = SUCCESSTEAM = SUCCESS

Summary

‣ If you do not know where you are going...any road will get you there

‣ Recipe for success = plan + timeline + milestones + defined deliverables + accountable individuals + a strong commitment from hospital leadership

‣ Think service line for high acuity medicine

‣ Anticipate, do not simply react

‣ Clinical details matter...decreased LOS, complications, mortality