boom, kata, kata: the story of inpatient days reductionmichiganlean.org/resources/documents/event...
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BOOM, Kata, Kata: The Story of Inpatient Days Reduction
Learning Objectives:
• Connect the use of traditional lean process improvement activity to better patient outcomes in healthcare
• Equip attendees with the knowledge for how this could be applicable in their own microsystem
Intro – What is GMLOS?
• Geometric Mean Length of Stay• Length of stay according to your working DRG for how long you are
‘expected’ to stay in the hospital• CMS pays organization based on this
• 3 Lacks was over by 1088 expected days
Why??
• Increased Cost of Care• Lack of communication for plan of care• Increased length of stay compared to expected • Delays in diagnosis, interventions, assessments, proper
disposition• No standard for care team rounding• 67 patient days are spent each month waiting for discharge after
the discharge order is placedPatients want VALUE: to be taken care of in the best and most
efficient way possible
Betty was the center of our work
Promote inter-professional communication and collaboration to decrease length of stay (LOS) and excess days on 3 Lacks
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11/19/19
The Flow of Patients
Current State
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11/19/19
Ideal State
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11/19/19
BOOM!!
Conduct Experimentsto get there removing one obstacle at a timeGrasp the
CurrentCondition
Establish your Next
TargetCondition
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THE FOUR STEPS OF KATA
Poster 1Kata in the Classroom / katatogrow.com
Get the Direction orChallenge
Our Improvement Methodology
What is Kata?
• Rhythm of practice• Scientific thinking / PDCA• Continuous Improvement• Experimenting your way to a better outcome
Kata Cadence: Improvement Kata
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11/19/19
Interdisciplinary team meets weekly for 1 hour to work through Improvement Kata cycle
Led by Bridget Graham, CNL on 3 Lacks
Kata Cadence: Coaching Kata
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11/19/19
Leadership participates in Coaching Kata weekly: CNO & Director, Director & CNL
Who was involved in the work
• Frontline staff• RNs, Physicians, PCAs, Social Work, Care Managers, Rehab Services,
Pharmacy
• Leadership (Barrier Breakdown)• CNL, CNS, Manager
What is our obstacle?
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1 0 0 1 0 1 0Behaviors Placement (SAR,
LTC)IV meds (lasix,
pain, BP, gtts, abx)Ready to go, ride
not availablePending consult
recommendationsDecision Maker Procedure (Drain,
ERCP, Thora x2, video x2, EGD, Picc
Med Titration Goals of care Pain PT/OT Eval Wean O2 Diet Advancement
Testing (VQ scan, MRI, Stress, Xray,
EEG)
Pareto -Why Can't the patient meet their GMLOS?
The Flow of Information
Standard for Inter-Professional Rounds
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11/19/19
Standard scripting developed to achieve TH standard for IPR
Weekly and Monthly Reports
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11/19/19
“Timecard”
PT/OT Trigger
43%
65%
80%
72%72%
89%
78%
87%82%
79%
87%
77%84%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 7 Week 9 Week 14 Week 18 Week 22 Week 38 Week 54
% PT/OT Orders Placed Within 4 Hours of Trigger
Increased physician and RN communication
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Week 1 Week 2 Week 5 Week 6 Week 37 Week 45 Week 57 Week 69 Week 81 Week 94 Week 108
Verbal Communication
IM Res FM Res Hosp Goal Linear (IM Res)
Create visual for what this new process did for improved communication – siloed vs. team communication
Patients discharged earlier in the day
0
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10:48 AM
12:00 PM
1:12 PM
2:24 PM
3:36 PM
4:48 PM
6:00 PM
Base
line
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& 1
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& 1
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& 2
0
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& 3
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& 3
6
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Min
utes
Tim
e of
the
Day
Discharge Order Written and Patient Discharged Timing
Ave.Discharge Order Written Time Ave. Patient Discharged Time Average time between patient discharged and order written
Improved Communication
0%10%20%30%40%50%60%70%80%90%
100%
9-Feb16-Feb
23-Feb2-M
ar9-M
ar
16-Mar
23-Mar
30-Mar
6-Apr
13-Apr
20-Apr
CM Notes w/ DC Plan and Transportation
% Documented Correctly
Goal
020406080
100
Baseline
Week 1
Week 2
Week 3
Week 4
Week 5
Week 41
PT/OT Compliance to Standard
PT
OT
020406080
100
May JuneJuly
AugustNov
Dec (12/6)
Dec (12/27)
Jan (1/5)
Jan (1/12)
Jan (1/19)
Jan (1/23)
Jan (1/31)
Feb (2/6)
Feb (2/14)
Feb (2/21)
Feb (2/28)
Mar (3/7)
Physician Progress Note with Template
IM
FM
Hosp
Goal
Organizational SpreadEach week, the unit was able to understand where they were at in relation to their overall goal for Excess Days using this barometer.
Tiered communication
Strategy meetingCNL MeetingUnit based improvement groupIndividual unit updatesIndividual unit coaching
The Flow of Staff
IDR RN Data
The Flow of Process
Organizational Changes
• 11 distinct process changes across inpatient nursing units (6)• Continued meetings with physician groups to maintain buy-in• Now continues to be the “way we work”, and looking forward to
new improvement
Outcomes
• Decreased Excess Days: 1.3 to 0.8 per patient• Decreased LOS:
• FY16 = 3.99• FY17 = 3.88 • FY18 = 3.82
• Decrease in excess days equates to a savings of over $250,000 per year
• Press Ganey Data
BOOM!!