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

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

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

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).

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

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

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

Methodology Outcome measures

TimePatient SatisfactionQuality and SafetyCost Effective Care

Methodology Pre-intervention

March 1 through October 31, 2008-2011

InterventionNovember 2011 – February 2012

Post-interventionMarch 1 through October 31, 2012

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

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)

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

Methodology—Cost Effective Care Average LOS

ED Volume

Total Admissions

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).

Time Interval Comparison

Time (minutes)

(Decrease of 78.8 minutes [417.8 – 339 = 78.8])

Statistically Significant, P-value <.0001

Time (minutes)

(Decrease of 35 minutes [168.5 – 133.5 = 35])

Time (minutes)

Statistically Significant, P-value <.0001

(Decrease of 36.2 minutes [61.9 – 25.7 = 36.2])

Time (minutes)

Statistically Significant, P-value 0.0015

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

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.

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:

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:

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:

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:

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%)

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.

Improved Inpatient Fall Rate

Falls significantly decreased (p-value < 0.0001)

Improved ED Left Without Being Seen (LWBS)

38% reduction in LWBS

p-value is < 0.0001

Improved Core Measure Compliance

Percentage of Perfect Care

Pre (%) Post (%)

P-value

AMI 91.41 100.00 0.0956

HF 84.35 100.00 <0.0001PN 84.99 94.44 0.0293SCIP 84.98 92.61 0.0006

Decreased Number of Rapid Response Team Calls

p-value = < 0.001

Statistically Significant

MortalityInpatient ED

p-value = 0.9053

No significant difference

p-value = 0.6264

No significant difference

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

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.

Improved Length of Stay

Average LOS decreased from 4.68 days to 4.36 days

(p-value < 0.0018)

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)

Cost Effective Care Summary Improved Average Length of Stay

Increased ED Volume

Increased Admissions

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.

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

Conclusion Further improvements are possible

Focus on specific time intervalsRe-evaluate processes

Lean Flow works and is an essential tool implement in healthcare.

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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