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Improving Risk-Adjusted Mortality Through Clinical Care Improvement And Documentation
Excellence
Transferring Patients To A Higher Level Of Care
Jeffrey S. Kuo, MD, FACEP, FAAEMMedical Director – Ochsner System Patient Flow Center
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
Ochsner Health SystemOur Mission is to Serve, Heal, Lead, Educate and Innovate
✓ Ochsner is Louisiana’s Largest Not-For-Profit Health System
✓ In 2018, Served 811,183 Patients From Across Louisiana, Every State, and More 70+ Countries
✓ 15 Owned & Managed Hospitals, 23 Affiliated Hospitals and 2 Specialty Hospitals
✓ 100+ Health Centers and 14 Urgent Care Centers
✓ 3 U.S. News & World Report “Best Hospital” Specialty Category Rankings 2018-19
✓ 1,345 employed and over 3,000 affiliated physicians in over 90 specialties & subspecialties
✓ Largest Private Employer in the State with 25,000+ Employees
✓ 288 medical residents and fellows work in 28 Ochsner-sponsored clinical programs
✓ 700+ Active Clinical Trials
✓ $3.1B in Total Operating Revenue; $5B With Financially Integrated Partners
Ochsner will be a global medical and academic leader who will save and
change lives. We will shape the future of healthcare through our
integrated health system, fueled by the passion and strength of our
diversified team of physicians and employees.
Our Vision
IMPACTING LIVES ACROSS LOUISIANA, THE NATION & THE WORLD
Who We Are Drives What We Do
Ochsner’s Core Values
6March 19, 2019
OHS Hospitals - Owned/Leased
OHS Hospitals - Managed/JOA
OHS Clinics
LEGEND
Ochsner Health System Locations (South East Region)
River ParishesLaPlace, LAManaged
ChabertHouma, LAManaged
Terrebonne GeneralHouma, LA
JOA
OMC - HancockBay St. Louis, MS
Leased
St. Bernard ParishChalmette, LA
Managed
St. Charles ParishLuling, LAManaged
St. Tammany ParishCovington, LA
JOA
Slidell MemorialSlidell, LA
JOA
OMC - BRBaton Rouge, LA
Owned
OMC - KennerKenner, LA
Owned
OMC - NSSlidell, LA
Owned
OMC - WestbankGretna, LA
Owned
OMC - St. AnneRaceland, LA
Leased
OMC - Jeff HwyNew Orleans, LA
Owned
OMC - BaptistNew Orleans, LA
Owned
Statewide Ochsner Health System & Network
Financially Integrated
Affiliated
LEGEND
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
• Up to 50 patients holding in Main Campus ED
• Regional Referral Center on gridlock
• Community hospitals on diversion
• 40-60 transfer requests without any facilities accepting
• 22,000 incoming phone calls to RRC in Jan 2018 (avg. 18,000)
Events That Provoked Immediate Intervention
2017-2018 “Flumageddon”
The Ugly Truth
• Capacity wasn’t balanced across the system
• Several community hospitals never held in ED overnight
• Hospitals were transferring out of the ED due to capacity concerns
• Diversion requirements varied substantially from campus to campus
• Many beds were available, just not staffed……………….and no one knew
Regional Referral Center Patient Volume
Transfer Volume: Disposition Indicator
39144686
5268 56256442
8718
1011510689 11173
11925
950 15542351
2627
3609
3998
6405
9363
11725
198
725
1235
1922
2250
198
822
525
600
0
5,000
10,000
15,000
20,000
25,000
30,000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019P
Accepted Telemed + Phone Consults Facilitated Transfer Free Standing ED-Accepted
5,6363,914
6,8227,976
9,123
12,525
15,036
19,151
22,983
26,500
Connecting Outcomes to Transfer Times
Time matters. Transferring patients in less than 6 hours saves lives.
Risk Adjusted Mortality Index (RAMI) For Transfers From External Facilities
LESS THAN 6 HOURS
5.1%
> 6 HOURS
7.8%
OBSERVED MORTALITY RATE(RAMI NUMERATOR)
LESS THAN 6 HOURS
6.5%
> 6 HOURS
6.2%
EXPECTED MORTALITY RATE(RAMI DENOMINATOR)
LESS THAN 6 HOURS
0.79
> 6 HOURS
1.26
RAMI
Problem Definition & Scope
Problem Statement: Process breakdowns and poor communication/information flow result in patient holds/throughput delays, putting us at risk for poor patient safety, quality, and experience.
• Routine operations require heroic efforts
• Patients wait too long in the ED, resulting to LWBS
• Admitted patients wait too long in the ED for a bed
• Transferred patients wait too long
• ER diversion and bed holds at community hospitals cause transfer delays
• Patients are delayed for days waiting to get to the right level of Post Acute care
• Patients are often discharged late in the day because of delayed Post Acute facility access.
• Patients wait too long to be flexed to a critical care bed or transferred to step down
• Patients are held in ORs and PACU
• Patients clinical risk is elevated due to lack of clinical information
• Patients receive care at locations that are higher in cost than necessary because of difficulties in access
Systems of Poor Patient Flow
• Collaborating with Epic as the IT platform for all patient flow
• Evolution towards centralized, system-wide bed management
• Building a command center to support system patient flow
• Approval for research & development of command centers via site visits
• Funding a “Quarterback”
• Development of standardized system protocols for patient movement including transfer acceptance
Events That Provoked Immediate Intervention
System Leadership Meeting
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
Learning From Others
• Operational improvements with key players in same room
• 60% improvement in acceptance of transfers
• Ambulance dispatch time improved by 63 minutes
• OR transport delays reduced by 70%
• Command center design is a true science
• Being off-site has advantages
• Patient flow is embedded in culture
• Easy access to data allows for real time analysis
• Optimizing hospital transport and EVS
• Use of a Quality Dashboard
• Internal hotline for DC delays
• QB Model for transfer acceptance
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Patient Flow Center design/build
• Leveraging technology/dashboards
• Culture change
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
• Chose a location
• Cost, construction needs, timeline
• Decided who needs to be in the room
• Roles and responsibilities for system vs division
• Planned for current and future needs
• Started to plan for colocation
• Alerts and phone calls vs face-to-face communication
• Technology and equipment
Patient Flow Center
Human Resources and Space Design/BuildWorkgroup included representation from:• Bed Planning• RRC• PFC• Flight Care• Telemedicine• IS• FF&E• HR• PILOT
Introducing The Patient Flow Center
Regional Referral Center
Centralized Bed Planning
Hospital Medicine PILOT
Behavioral Health Placement Team
Case Management
Flight/Ground EMS Dispatch
Non-Emergent Transportation Dispatch
Patient Flow Center Administrative Lead
Facility and Hospital Capacity Statistics
Transfer Patient Tracking
Transfer Center PILOT Dashboard
Driving Results With Technology
Original Workflow Automated Workflow
Transfer Center Model
Requesting Provider inputs Transfer Request or Calls RRC
PILOT, RRC RN & Case Mgmt, review case. Acadian alerted of potential transport
RRC & Pilot have MD to MD; accept transfer, enter admit order
PFC House Sup. Assigns Bed
Requesting facility to RRC
RRC to community AC
RRC to potential accepting MD, MD to MD
AC to RRC with bed assignment
RRC to Acadian
RRC to sending facility
AC calls accepting to input admit order
Accepted
Transfers
Telemedicine
Consults
October YTD Volume Comparison
+54%+6%2017:8,785
2018:9,299
2017:3,561
2018:5,467
• Executive led initiative
• Executives from every campus were involved in project work
• Regional Referral Center (RRC) became a system entity
• Patient Flow Center functions are part of system strategic plan, presented to OHS Board, System Leadership meetings, CNO councils, etc…
• Patient flow stats reported out in Daily Connection
• Everything is now transparent:
• PFC Daily Huddle – Transfers, Misses, Declines, etc…
• Automated Shift Reports - Staffed beds, bed blocks, holds, etc…
• Bed Assignment Decline Reports
Culture Change
“Change Ain’t Easy”
Tier 1Frontline
Department Huddle
Tier 2Division DON,
Director, AVP, VP Huddle
Tier 3Division/Region Executive Team
Huddle
Tier 4System Executive
Team Huddle
7am-8:25am/pm
8:30am-9:25am
9:30am-9:55am
10:00 am
In Real-Time: Tiered Huddle Escalation Report
Over-Time: Solutions Cascaded: Stoplight Reports, Leader Rounding Communications, Open Forums etc.
What Gets in The Way of Doing Our Best for Our
Patients Every Day?
Live System-Wide
• Ochsner Health System Overview
• What provoked “immediate intervention”
• Learning from other systems
• Structuring the command center
• Physician In Lead of Transfers (PILOT)
Improving Risk Adjusted Mortality
Transferring Patients To A Higher Level Of Care
PILOT (Physician In Lead Of Transfers)
Plan of Care
Discussion
Prioritization Levels
Resource Utilization
Communication Improvements
Leading To Decreased
Hand-Off Errors
Auto-Launch: Auto-acceptance with parallel processing of transfer and transport
I. Increased risk of adverse outcome if not transferred now (goal bed assignment 1 hour/arrival 3 hours)
II. Increased risk of adverse outcome if transfer not complete within 6 hours (goal 2/6)
III. Higher level of care requirement without time-sensitive issue
IV. Deemed appropriate for outpatient evaluation/follow-up
V. Transfer not indicated medically
Ochsner System Patient Flow Center PILOT
Acuity Level Designation
PILOT (Physician In Lead Of Transfers)
Risk Adjusted Mortality Index (RAMI) Of Transferred Patients
2017:0.91
2018:0.77
Pre:0.91
Post:0.67
Pre:0.57
Post:0.34
Pre:0.91
Post:0.81
Pre:0.67
Post:0.37
PILOT (Physician In Lead Of Transfers)
“The 2/6 Initiative”: Assigning Levels And Time Goals To Transfers
Goal
Bed assigned: 1 hrIn Facility: 3 hrs
Expected Mortality
Observed Mortality
RAMI
1.9% 6.1% 3.31
Expected Mortality
Observed Mortality
RAMI
17.5% 0% 0.00
Bed assigned: 2 hrsIn Facility: 6 hrs
2.5% 4.8% 1.88 1.1% 0% 0.00
Level
2
Level
1
Goal Not Met Goal Met
• Patient flow and transfer acceptance must be embedded in the culture of your organization
• Placing key stakeholders in the same room improves patient flow communications
• Avoid handoff errors through improved communications and thorough documentation
• Transferring patients for a higher level of care in a timely manner saves lives
Improving Risk Adjusted Mortality
Key Takeaways
Transferring Patients To A Higher Level Of Care