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Advancing Strategic Goals through
Hospitalist ExpansionBecker’s Hospital Review April 1, 2019
Carle Foundation HospitalLynne Barnes, Chief Operating OfficerDr. Saad Adoni, MD, Hospitalist Associate Medical DirectorEmily Myers, Manager, Hospital Medicine Physician Practice
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Welcome to Carle
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Mission and Vision
OUR MISSION
We serve people through high quality care,
medical research and education.
OUR VISION
Improve the health of the people we serve by
providing world-class, accessible care through an
integrated delivery system.
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Carle at a Glance
2018
Hospital Beds 413
Average Daily Census 380
Admissions 30,962
Births 2,809
Emergency Department Visits 90,781
Health Alliance Members 230,644
Clinic Visits 824,445
Carle Physicians 597 + 307 APPs
Carle Foundation Hospital
o Level I Trauma Center
o Level III Perinatal Services
o Primary Stroke Center
o Neonatal ICU
o Wound Healing
o Sleep Lab
o Spine Institute
o Heart and Vascular Institute
o Carle Cancer Center
o Mills Breast Cancer Institute
o Bariatric Services
o Palliative Care
o Digestive Health Center
o Carle Research Institute
o Pediatric Affiliation (CHOI)
Carle Physician Group
o Multi-specialty clinic-80 specialties
o Clinical Trials
o Reproductive Medicine
o Oral and Maxillofacial Surgery
o Hearing/Audiology
o Eye/Optical Shop
o Pain Center
o Geriatrics
o Primary Care
Other Business
o Carle Medical
Supply
o Carle Home
Services
Other Business Units continued
o Carle Therapy Services
o Carle Auditory Oral School
o The Caring Place: childcare
o Stratum Med: recruitment, GPO
o Windsor of Savoy: retirement
community
Units
o Carle Sports Medicine
o Carle SurgiCenters:
Champaign & Danville
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A Broad Service Area Receives Clinical Services Through Carle
1,381,170 Carle Service Area Population in 2017
80+Specialties and subspecialties
Level I Trauma CenterLevel III Perinatal
24 bedsCarle Hoopeston
Regional Health Center
134 bedsCarle Richland
Memorial Hospital
413 bedsCarle Foundation Hospital
43+ physiciansCarle Hoopeston
Regional Health Center
10 physiciansCarle Richland
Memorial Hospital
597 physiciansCarle Foundation Hospital
44 APPsCarle Hoopeston
Regional Health Center
10 APPsCarle Richland
Memorial Hospital
307 APPsCarle Foundation Hospital
10,816 ED visitsCarle Hoopeston
Regional Health Center
9,633 ED visitsCarle Richland
Memorial Hospital
90,781 ED visitsCarle Foundation Hospital
6 countiesIn West Central IN
29 countiesIn East Central IL
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Carle Service Area Health Alliance Network
230,994Total Lives
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Dyad Leadership is a "work" marriage combining administrative leader with a physician leaderThe partners balance skills and strengths and work as a cohesive team towards common goals.
ADMINISTRATIVE LEADER
o Management skills
o Clinical credentials
o Persistent, organized, detailed
o Relates well across organization
COMMON GOAL PHYSICIAN LEADER
o Sterling clinical credentials
o Excellent relationship and influence skills
o Systems thinker
o Develop department and high-performing team
o Establish effective communication between admin and physicians
o Solve complex department problems
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• Historical Successes, Struggles, and Engagement
• Establishing the Hospitalist as leaders in Safety, Quality and Service
• Future program goals.
Agenda
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Successes, Struggles, and Engagement
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Success: Whiteboard Rounds
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Success: 2018 Committee ParticipationCommittee Name Hospitalist Representative
Surgery PPC, IP Best Practice Adoni, Saad
Inpatient Diabetes Committee Afzal, Ommar
Fall Reduction Workgroup Ahmed, Mohammad
Medical PPC, Chest Pain Accreditation Alcaraz Jr , Renato
Hospitalist Physician Wellness Alcaraz, Ellaine
Stroke Program Committee Al-Heeti, Ommar
Medical PPC Are, Chaitanya
Inpt best practice committee Arwari, Andy
UPC Rog 6 Asapu, Eswara
High Quality Dysphagia Chakumgal, Sreenu
Observation Meeting Elman, Arnolfo
Inpatient Sepsis Multidisciplinary WorkgroupGao, Lianghe
Triage RN Monthly Staff Meeting Ginne, Purshotham
Carle Mortality Committee Gong, Chunling
IP Best Practice Grindem, David
Antimicrobial Stewardship Committee Haider, Baqer
SNF collaboration readmission and discharge Hashmi, Nazneen
UPC NT6 Hsu, Sean
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Struggle : Staffing
• Patient volume growth at the same time of not hiring up to demand– Physicians committed to ~100 extra shifts per month
• Short over 10 FTE’s – Created a need for those to work extra shifts
• Increased Physician burnout
• Doubling or splitting teams to address gaps in coverage
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Struggle : SchedulingPhysicians Self-Scheduling
Allowed for Flexibility in Shift Preferences• Days, evenings, nights, etc
Created multiple 1-2 day gaps in coverage• Increased # of hand-off’s between day rounding teams
• Increased LOS for our patients
• Patient Dis-satisfier
• Nursing Dis-satisfier
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Struggle: Efficiency
• Average starting census was 15-16 patients with total encounters of 18.
• Large gap between discharge efficiency and starting census
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Struggle -The Metrics
•ALOS
•CMI
•Readmissions
•Patient Satisfaction
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Average Length of Stay
Target
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Case Mix Index (CMI)
Target
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Readmissions
Target7%9%
11%13%15%17%19%21%
Jan
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Mar
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May
July
Sep
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No
vem
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Jan
uar
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Mar
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May
July
Sep
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be
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No
vem
be
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Jan
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Mar
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May
July
Sep
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be
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2016 2017 2018
Readmission Rate
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Patient Satisfaction Scores
Target
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Establishing the Hospitalist as leaders in Safety, Quality and Service
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Hospitalist Mission Statement
The Carle Hospitalist Institute is comprised of a group of physicians dedicated to providing evidence based care and striving to be the agents of safety and quality for the patients we serve.
We are here to provide leadership for the patient experience, as well as serve as role models for compassionate and accountable care leading to the best possible outcomes for Carle Hospital patients, their families, the care team, and the community.
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Hospitalist Vision
Carle Hospitalist Institute’s vision is to lead Carle Hospital toward top decile performance across all quality and service metrics through leadership and care rigor.
Our team will be viewed as the leaders of care within our hospital reflecting a physician led and patient centered culture that draws the best and brightest of providers and staff.
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Scheduling• One week on, one week off block scheduling, all shift
types
• Change to 7am to 7pm Scheduling
• Limit to 1 shift in 24 hour period
• Change of Service Days will be Wednesdays
• All Hospitalist Patients equally distributed
• Reset on Unit Integrity
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Scheduled Shifts• Standardization of the Swing Shifts: Three 10-hour swing
• 4pm – 2 am• Standardize the Nocturnist Shifts
• Night Triage• Cross-Cover• Night Admitting Shift
• Backup• No backup.• If calling in sick, physician expected to seek their own
back up coverage.
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Operational Improvements
• Day Rounding expected to have 2 admits until 5pm.
• Equal Distribution of all patients admitted by swing or Nocturnist Hospitalist
– Equal Distribution trumps Unit Based Integrity
• All “Census Cap” Policies will be removed
• Hospitalists arrive at the designated time for WB rounds
• Remain available and onsite to patient load from 8a –5p
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Operational Improvements
• 3pm huddles for all the Rounding Teams
– UNL, Care Coordinator
• Discharge summaries completed and EPIC inbasketqueries responded to prior to leaving shift
• Combined Admin / Quality Meeting to promote networking and collegiality
– Offsite and after hours to increase attendance
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Sweet Spot Revisted
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Physician Satisfaction• Equal overnight distribution
• Incentive to discharge patients
• Lower starting census– From 16 – 18 patients to 12 – 13 patients
• More time to spend with patients
• Work on discharge summaries for today/ tomorrow
• More structure, less stressful days– Lower potential for physician burnout
• Increased collegiality between group
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What’s Next…
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One Pipeline Process
• All transfer patients from the region assessed in Observation designated unit prior to admission
– Includes Regional Referrals, PCP office, Conv. Care
• Triage Hospitalist accepts the patient
– The triage hospitalist screens the patient upon arrival. This is the added step that confirms the patient condition matches the current bed placement plan. Care orders initiated/consults are contacted as appropriate.• Physician Response Time: 20 minutes
– Case Management reviews inpatient criteria
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One Pipeline Process
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Documentation Improvement Resources
• On-Site Clinical Documentation Information training session for physicians
– Group format with lead physician trainer
• 2 CDI physician leads within Hospitalist Group
– Training and feedback for Hospitalists
• Monthly feedback on opportunities and data
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Improving WB Rounds
• Physician Led
• Focus on day to day care
• lacking sense of ‘urgency’
• Undefined date of discharge– “2-3 days”
• Nurse- Physician Led, new scripting
• Focus on discharging patients
• Targeted LOS for diagnosis and current LOS
Previous: Future:
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Transitional Care Clinic• Outpatient intervention-post discharge clinic.
– Transitions in care from an inpatient hospital setting to the patient’s home.
– Patients will be seen within 72 hours post discharge.
– Targets high-readmission risk patients.
• Staffed by Hospitalists, extension of the inpatient stay
• Success:– Reducing readmissions to hospital within 30 days
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Enhancing Relationships/ Communication
• Partnership Council
– Raise awareness and success for Hospitalists as the Quality and Safety Champions in the Hospital
– ED Physician, Critical Care physician, Nursing Leadership, Case Management, Triage RN, Patient Experience Team
• Nursing / Case Management Survey
– Gain feedback on Hospitalist program• Perception
• Availability
• Efficiency
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Carle Board ReportKey Metric Description and Rationale 2018 Baseline 2019 Target 2019 YTD
ALOS
Average Length of Stay for Inpatients: A lower LOS typically
indicates more efficient use of resources and reduces the risk
of hospital acquired conditions for patients. 4.86 3.87 4.73
Observed : Expected
Length of Stay
Based on CMS benchmark LOS; this is how Carle compares
with similar patient types for length of stay. The closer to 1.0,
the more accurate the length of stay comparison. 1.25 1.12 1.20
Case Mix Index (CMI)
The measure of the acuity of a patient derived from the
documentation provided by the physician. A higher CMI
indicates higher acuity and resources needed to treat the
patient. 1.43 1.50 1.53
Discharge Efficiency
The average number of patient discharges divided by the
total number of patients on an individual physician panel.
This is a measure of a particular physician’s effectiveness in
helping a patient move through their course of hospital care. 21% 25% 22%
Readmission Rate
The number of patients discharged from the hospital who
return to the hospital for an admission within 30 days. 18% 15% 19%
3PM Huddles
These daily huddles take place on each unit in order to
facilitate any needs for the patient and/or family before the
rounding physician leaves for day. This “huddle” provides an
opportunity for any nursing or patient/family care questions
to be addressed in person by the physician.
The “huddle” also drives discharge by focusing on patients
discharging today or tomorrow. 0% 80% 100%
Hand off Note compliance
These notes provide any meaningful information that should
be conveyed to the next physician who is taking over care of
the patient, both overnight and each week when the
physicians transitions on and off service. 0% 80% 100%