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Transforming Emergency Care with Analytics and Technologies
Linda Hummel, MS, BSN, RNVice President
Quality and Patient SafetyMission Health System
Rick Lee, MSN, RN, CEN, NE-BCExecutive Director
Emergency ServicesMission Health System
Session 34:
Learning Objectives
Represent the impact the system
of care has on emergency department
(ED) performance.
Identify how increased leadership visibility and engagement contribute
to success.
Demonstrate the power in using data to drive
each step of the improvement process.
Recognize the importance of focusing
on the patientand family experience.
About Mission Health• Mission Health is western North Carolina’s only
not-for-profit, independent communityhealthcare system.
• Mission’s BIG(GER) Aim is to get every person to their desired outcome, first without harm, also without waste, and always with an exceptional experience for each person, family, and team member.
• Employing over 13,000 dedicated professionals, the system is comprised of seven hospitals including tertiary, critical access, and inpatient rehabilitation, 750 employed/aligned providers, and one of the largest Medicare Shared Savings ACOs in the nation.
Poll Question #1On average, what percentage of hospitals report frequently operating “at” or “over” capacity?
a) 10 percentb) 30 percentc) 50 percentd) 70 percente) 90 percentf) Unsure or not applicable
The Situation at Mission Health
Patients were walking out of the emergency department.
Large numbers of patients, upwards of 4,000 a year, were walking out of the ED without being seen by a provider.
Excessive wait times.
On average, patients waited more than 50 minutes to see a qualified medical provider after being triaged by the registered nurse.
Volumes were negatively impacting throughput and the patient experience.
Median LOS for patients who were discharged = 237 minutes.
Median LOS for patients who were admitted = 316 minutes.
Median LOS for behavioral health =700 minutes.
Patient feedback was in 1st percentile.
How We Redesigned the Delivery of Emergency Care
Began with the BIG(GER) Aim and asked “What do we
need to best deliver emergency care?”
Created a vision and support for a data-driven systems approach to
improving emergency care.
Using the analytics platform, developed an ED analytics
application-providing insight into performance.
Engaged frontline staff, key stakeholders, patients, and
families in improvement.
Understanding ED Performance
ED Explorer Advanced Analytics Application
ED Performance
Physician Performance
Metric Comparison
Admission Trend
Understanding Patient Arrival Time and Impact on ED Throughput
Decreased throughput.
65 arrivals within three hours.
50 arrivals within two
hours.
30 arrivals within an
hour.
Revising High Impact WorkflowsCommunicated leadership expectations.
Revised staffing patterns.
Improved triage workflow.
Restructured the registration process.
Improved response to surges in patient volume.
Improved the patient experience.
Earlier access to a qualified medical provider.
Redesigned the discharge process.
Implemented readiness huddles.
Setting Leadership Expectations
• Executive director and director actively engaged in the department.
• Chief nursing officer and vice president of quality and safety identified as executive sponsors for the improvement work.
• Added a flow coordinator from 1700-2300 to oversee all hospital patient flow.
• Vice president on-call expectations:– Round on a daily basis-recommend after 1700.
– Participate on surge calls if needed.
– Round at least once during the weekend.
– Leaders receive and review daily performance reports.
Poll Question #2
On a scale of 1 to 5, how effectively is your organization using patient volume data to inform staffing plans?
a) 1-Not at all effectiveb) 2-Somewhat effectivec) 3-Moderately effectived) 4-Very effectivee) 5-Extremely effectivef) Unsure or not applicable
Revised Staffing Patterns• Retrospective three year review of ED census/staffing.
• Identified seasonality in volume trends.
• Identified five weeks with consistently high volume across the three-year period.
• Utilized this data to predict upcoming high-volume periods.
• Adjusted staffing matrix to meet the trends.
• Historical trends used to plan for upcoming holidays and other identified periods of high census.
• Historical trends used to open and close sections of the ED to align with demand.
Understanding Surges in Volume
Census 587 Total 685
Occupancy 81% Closed 11
Discharges 31 Available 149
MH Campus 417 80%STJ Campus 170 83%
Virtual Bed Census 0 0%
1)
2)
3)
4) Prev. Day 59%5) Target 65%
Care Area Current Census
Physical Beds
Closed Beds
Available Beds
Discharge Orders
Current Occupancy
Care Area Current Census
Physical Beds
Current Occupancy
Wait Room Census
Pts Still to Triage
Admission Patients
Discharge Patients
Adult Intensive Care 48 61 4 9 2 84% Emergency Room 33 65 42% 6 6 1 1
Adult Med/Surg 277 327 6 44 20 86% ED Main 12 5 240% 6 11 32 Door to Doc 11 0
Observation 15 15 0 0 0 100% PEA 22 23 96% 1 130 0 Med LOS 83 0
476 552 10 66 25 88% B3 South 6 24 25% 1 4 4 2
40 52 77% 0
Care Area Current Census
Physical Beds
Closed Beds
Available Beds
Discharge Orders
Current Occupancy
Surgical Area
Scheduled InOR PTS in PACU
PACU Admits
Surgical Area
Scheduled InOR PTS in PACU
PACU Admits
Adult Psychiatric 32 33 1 0 0 100% MOR 49 6 1 1 SOR 26 6 0 0
Geri Psychiatric 8 8 0 0 0 100% MENDO 15 2 0 0 SENDO 0 0 0 0
Adol Psychiatric 9 9 0 0 0 100% COR 7 3 0 0 VOR 6 0 0 0
Child Psychiatric 8 8 0 0 0 100% WOR 1 0 0 0 32 6 0 0
57 58 1 0 0 100% 72 11 1 1
Care Area Current Census
Physical Beds
Closed Beds
Available Beds
Discharge Orders
Current Occupancy
Facility Transfers
Women Services 33 60 0 27 4 55% Angel 0
Mission Childrens 41 79 0 38 2 52% HighLands 0
74 139 0 65 6 53% Blue Ridge 0
Transylvania 0
Regional Holds 0
PACU SPECIFIC NEEDS ED SPECIFIC NEEDS
Current Occupancy91%
Service Time3
LWBS Daily Count
0
EMERGENCY SERVICESADULT MEDICINE/SURGICAL
Care Level Need
Waiting Room
Current Census
Physical Beds Max Time
Avg Time (mins)Volume
Admission
Non Member Regional Holds
CLOSED BEDS
Mission Memorial Campus St Joseph Campus
A507- infection prevention 6 North x 5 Beds; Coli Annex x 4; CS 503- shower
McDowell 0
WOMEN'S AND CHILDRENS
BH OBS
SURGICAL SERVICES/OPERATING ROOM
REGIONAL MEMBER HOSPITALS
BEHAVIORAL HEALTH
Adult Stepdown 136 149 0 13Avg Time
(mins)Service
Time
Disharge
Snapshot RunMedical Beds OnlyCurrent Occupancy
04/23 8:43
KEY MESSAGES Key Performance - Previous Day
45 MINS 35%25%
Percent of Discharges by 12 PMBack 120 %
Yield Discharge Order to Discharge (90 Mins)
26%
Assign/Available to Transfer Complete
156 mins 17%
Emergency Service Surge
Current Real Time Surge Monitoring
Mission Hospital Surge
Coordinated System Response to Surges• Implemented operational surge
plans; plans outline responses for each clinical program and ancillary service.
• Advanced access to primary care is anticipated to begin Q1 FY17.
• Coordinated wrap-around service needs, internal and external to the organization.
Visual Indicator Responses
Green Normal business operations – AM ED Huddle - daily capacity email updates – Administrative Supervisor Capacity Huddles – Daily Regional Huddles.
Yellow
Shift Coordinator for Mission Care Coordination Center(MCCC)/ Nursing Administration Supervisor:
• Additional Nursing Capacity Huddles PRN • Huddle with Care Management on focused discharges • Huddle with ED on current holds and resource needs • Allocate available resources to support holds/ ED / Discharge needs / PACU Holds • OPE notified to complete ED Waiting Room Rounding
Orange
Addition of Capacity Huddles at q4 Hours with the following:
• Administrative Supervisor • Care Management • Nursing – Manager or Director from all in-patient units • ED Nursing – Manager/Charge RN • EVS Leadership • PACU • RTS
Mission Direct Holding non-Emergent Regional Transfers
OPE notified to complete ED Waiting Room Rounding
AOC Notified
Additional Regional Huddles as Needed
Red Addition of the following to Daily Huddles and additional Huddles (PM and every 4 Hours) as needed per Administrative Supervisor/ AOC:
• AOC/ AOC VP if not already included
Restructured Registration Process
Patient registration was experiencing increasing wait times at check in.
Previous registration process included 17 questions at point of entry.
Removed questions that did not provide value at the point of entry, implementing a quick registration process with only three questions: name, DOB, and chief complaint.
Improved patient flow from quick registration through completion of triage.
Implemented a phone and texting application to improve private communications with patients and families.
Updated surge protocols to include to include guest services and Mission patient experience staff during high waiting room volumes.
Improved Triage Workflow and Earlier Access to a Qualified Provider• Re-confirmed use of the Emergency
Severity Index (ESI) triage acuity scale.
• Revised the initial list of questions asked at triage.
• Implemented an early team evaluation protocol.
• Developed a new role – triage advanced practitioner.
Redesigned the Discharge Process
Former discharge process had dedicated staff and location for one single point of discharge.
Time of “disposition decision to departure” would exceed60 minutes.
Feedback from patients was that the single point of discharge did not add value.
Redesigned the discharge process, moving it back to the patient’s bedside.
Ensuring Data-Driven Daily Readiness • Introduced team-based care huddles.
• Originally held at 1400 in line with patient flow and high-volume periods.
• Includes nursing leader, oncoming ED providers, environmental and guest services, hospitalist, and house supervisor.
• As efficiencies led to improved workflows, huddles were changed to 0630.
• Huddle agenda uses patient flow data, and includes current state, challenges, resource needs, and changes.
Ensuring Data-Driven Daily Readiness
Improving the Patient Experience• Pursued the “voice” of the patient (feedback from patients, focus groups,
patient complaints, etc.).
• Facilitated weekly huddles to review patient feedback.
• Leadership made clear that the patient experience was a priority for the entire team.
• Exchanged “security” FTEs for “guest” services.
• Conducted patient experience training in the simulation lab.
• Active care management (embedded care manager within ED).
• RN ED navigator assists patients navigate the ED and conducts discharge phone calls.
• Leaders perform rounds daily.
• Reinforced common best practices and expectations.
Improved Patient Experience - Overall Quality of Careand Likelihood of Recommending
0
10
20
30
40
50
60
70
80
90
100
Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18
Overall Quality of Care
% Excellent 47.2 48.1 54.6 57.8 48.6 57.4 52.8 59.6 48.0 47.4 56.9 52.4
ED 50th Percentile 50.5 50.5 50.5 50.5 50.5 50.5 51.3 51.3 51.3 51.3 51.3 51.3
N of Cases 108 108 108 109 107 108 108 114 102 135 102 84
Norm Year 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017
Ranking are based on PRC Norm dataMarked bars are Statistically SignificantExcellinkTM = ‘ED OQC and Likelihood to Recommend Monthly’
0
10
20
30
40
50
60
70
80
90
100
Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18
Likelihood of Recommending to Friends / Relatives
% Excellent 48.1 51.9 58.7 54.2 51.9 56.6 59.0 64.3 45.5 45.1 59.4 45.9
ED 50th Percentile 49.3 49.3 49.3 49.3 49.3 49.3 49.8 49.8 49.8 49.8 49.8 49.8
N of Cases 106 106 109 107 104 106 105 115 101 133 101 85
Norm Year 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017
Results
70%relative reduction in time to complete registration.
89%relative reduction in the rate of patients who left without being seen.
85%relative reductionin percentageof patients who left before treatment complete.
33%relative improvement in time from patient arrival to triage start time.
75%relative reduction in median door to assessment by a qualified provider, with current performance under 15 minutes.
29%relative reduction in the time from discharge order to ED departure time.
24%relative reduction in the median length of stay (LOS) for patients who are discharged.
15%relative reduction in the median LOS for patients who are admitted.
42%relative reduction in median LOS for patients with behavioral health needs.
Threefoldimprovement in patient ranking for overall quality of care and provider communication.
Improved Timely Access to a Qualified Medical Provider and Door to Doctor
Improved Patient Left Without Being Seen and Left Before Treatment Complete
Lessons and Recommendations
Recognize quality improvement is a
journey that takes time.
Improving ED throughput is much
more than an emergency department
initiative – you must include the entire system of care.
Manage by fact –data tells the truth. Using a data-driven approach can help
engage stakeholders and make a compelling
case for change.
Changing the entire system of care requires
your best leadership skills, and is challenging work. Pace yourself so you can effectively lead
the change.
Questions and Answers
Linda Hummel, MS, BSN, RNVice President
Quality and Patient SafetyMission Health System
Rick Lee MSN, RN, CEN, NE-BCExecutive Director
Emergency ServicesMission Health System
