boston chicago new york san francisco september 20th, 2005 maryland association of healthcare...

Boston • Chicago • New York • San Francisco

September 20th, 2005

Maryland Association of Healthcare Executives

The Ideal Patient Experience and the Importance of Improving Patient Access

©2005 The Chartis Group 2

Today’s Agenda

Defining the Ideal Patient Experience

The Case for the Ideal Patient Experience

Patient Access and Achieving the Ideal Patient Experience


“Most hospitals are islands of clinical excellence surrounded by the DMV”

- Ian Morrison (Health Care Futurist)

What is the Ideal Patient Experience ?

©2005 The Chartis Group 4b

The Ideal Patient Experience is the

result of a provider orienting its entire organization and

processes to deliver clinical excellence in

the context of an optimal patient

encounter



Clinical Excellence• Superior Patient

Outcomes Across the Continuum

• Unparalleled Patient Safety

• Integrated Teaching and Clinical Care Platform

• Research that Spans the Spectrum from Bench to Bedside



Excellence in Care Delivery

• Compassionate Family Centered Care

• Coordinated Care in the Optimal Setting Across the Continuum for the Patient and Family

• Easy Access and Seamless Scheduling and Use of Resources

• Effective Referring Physician Education and Service



Operational Excellence

• Easy Patient and Family Access to and Navigation of the System

• Singular, Consistent Generation of Patient, Family, and Provider Information

• Cost Effective Delivery of Care and Services

• Ease for Physicians and Personnel to Provide Service



The Ideal Patient Experience

The Ideal Work Experience

• Patients• Families

• Physicians• Employees



Today’s Agenda





The Patient Perspective

2001 was the first year that over 50% of patients surveyed responded that their hospital preference would supercede their physician’s recommendation

In 2001, consumers ranked hospital reputation over physician recommendation in terms of determining factors when choosing a provider

Out-of-pocket costs to employees are growing – healthcare premiums projected to increase 7% above wage increase index

Unconstrained healthcare knowledge access via the internet

Rise of the educated consumer who demands healthcare services and choice

Studies have shown that patients who have a suboptimal experience accessing services also are more prone to poor satisfaction scores with their inpatient stay and are less likely to recommend the provider

Consumerism: Not just a concept anymore


The Patient Experience, The Physician Experience and The Employee Experience

• Ease of Use• Ease of Access• Quality of Care• Coordination of Care• Affordability

Choice will be Driven by the Total Experience

Charles Schwab meets Disney meets the Mayo Clinic


Success in the next five to ten years will go to the institution that provides The Ideal Patient Experience

Consumers: Our patients and families demand it and will choose because of it

Employees: The Ideal Patient Experience provides and relies upon The Ideal Work Experience – necessary in these labor markets

Physicians: Unparalleled ease, effectiveness and quality – they channel patients

Payers: It will be the institution of choice – a great source of leverage

The Case is Made


Today’s Agenda





Top Processes which Drive Patient Experience

Core Patient Processes

• Respect for Patient’s Values, Preferences and Expressed Needs

• Coordination and Integration of Care

• Information and Education

• Physical Comfort

• Emotional Support and Alleviation of Fear and Anxiety

• Involvement of Family and Friends

• Transition and Continuity

• Access to Care

Defining Quality – From the Patient’s Perspective1

• Patient Access and Flow

• Care Delivery

• Care Coordination

• Deliver Diagnostic Services

• Therapies, Intervention and Support

• Workforce Recruitment, Retention and Development

1 National Research Corporation / Picker Institute


The Ideal Patient ExperienceCore Process Hierarchy

Patient Facing

Processes

Infrastructure

Patient Support

Processes

•Patient Access and Flow •Care Coordination•Care Delivery•Communication and Education•Dietary Services

•Revenue Cycle and Billing•Environmental Services•Facility Services

•Information Management•Supply Chain Management

Core Patient Processes


Why Is Patient Access and Capacity Enhancement (PACE) Important?

Characteristics of Providers Who Invest in Patient Access and Capacity Enhancement

• Wide swings in average daily census (low on the weekends, peaking Wednesday/Thursday).

• Wide swings in hourly census

• Operationally “full” facility, yet reporting 20% of beds as unoccupied

• Periodic capacity bottlenecks (ED, OR, ICU’s)

• Seemingly endless game of “musical chairs” in an effort to find capacity

• Significant physician, staff and patient frustration with patient flow

• Significant energy and resources expended to facilitate patient flow and maximize capacity utilization…but with unclear results

• Wide swings in average daily census (low on the weekends, peaking Wednesday/Thursday).

• Wide swings in hourly census

• Operationally “full” facility, yet reporting 20% of beds as unoccupied

• Periodic capacity bottlenecks (ED, OR, ICU’s)

• Seemingly endless game of “musical chairs” in an effort to find capacity

• Significant physician, staff and patient frustration with patient flow

• Significant energy and resources expended to facilitate patient flow and maximize capacity utilization…but with unclear results


Background and Our Understanding

Top Reasons Clients Focus on PACE

• Support/enhance patient safety initiatives/further promote safety as one of the organization’s top priorities

• Arrest and improve steadily eroding patient and physician satisfaction levels

• Achieve targeted volume growth

• Protect and promote patient sources which could be compromised by emergent access patients (e.g., elective procedures)

• Open additional capacity currently “closed”

• Avoid/minimize or improve return on investment of planned capacity expansions

• Promote ease of access to care as a top priority and differentiating factor

• Support/enhance patient safety initiatives/further promote safety as one of the organization’s top priorities

• Arrest and improve steadily eroding patient and physician satisfaction levels

• Achieve targeted volume growth

• Protect and promote patient sources which could be compromised by emergent access patients (e.g., elective procedures)

• Open additional capacity currently “closed”

• Avoid/minimize or improve return on investment of planned capacity expansions

• Promote ease of access to care as a top priority and differentiating factor


Bed Demand Management Unfettered

patient processing

PACE imparts equal focus on addressing the supply of available beds and the processes that impact the demand for patient beds.

Bed Supply Management Achieving maximum bed

availability

Key Drivers of PACE Improvement

• Practices and Policies• Bed Allocation• Scheduling

• Intake efficiency • Discharge and Bed

Turnaround

Overview of Our Approach to PACE

• Increase available capacity

• Increase capacity utilization

• Increased physician satisfaction

• Improved patient safety

• Increased patient satisfaction

• Increased volume at lower capital costs

Outcomes Results


Entry Channel 1(e.g. ED)

Entry Channel 2(e.g. Specialty Clinic)

Entry Channel 3(e.g. Multiple Others)

Bed Management Policy

Bed Management Processes and Practices

Patient Entry Processes

Patient Placement Processes and Practices

Discharge Planning

Communications

Data, Information and Measures

Patient/Bed Aggregation

Case Management

Staffing

Scheduling

Information Collection

Physician Practices

Procedural and Ancillary

Services

Diagnostics

Environmental Services

Infection Control

Means of Access

Bed ManagementAnd Patient Placement

Inpatient UnitOperations

Pt. Care and Support Processes

PACE Process Framework

Overview of Our Approach to PACEWe view PACE as a series of interdependent complex processes, in which changes in one process or area can have significant, and potentially unintended consequences, on the whole.


Direct Admit:• Single consistent entry process/path for same day non-

emergent admissions−Consistent points of entry−Ease of use for admitting MDs−Consistent service acceptance process built around

facilitating entry−Consistent unit reception

• Accessible and timely patient transport

Emergency Department:• Disciplined definition and use of ED for emergent cases

vs. direct admissions or pre-admission work-up staging• Consistent service acceptance process built around

facilitating entry• ED is selectively used as ancillary support after bed

assignment• Accessible and timely patient transport

Elective Procedures:• Restructured OR block times to smooth downstream

capacity utilization• Incentives for surgeons to utilize less popular OR times

Best Practice: Means of Access

Communications


Discharge Planning

Entry Channels

BedManagementAnd Patient

Access

InpatientUnit

Operations

PatientCare andSupport


Best Practice: Demand Management

Scheduled Daily Admits by Case Type - Before

0

1

2

3

4

5

6

7

8

M T W R F S S

Major

Minor

Scheduled Daily Admits by Case Type - After

0

1

2

3

4

5

6

7

8

M T W R F S S

Major

Minor

Unit ADC Before & After Schedule Changes

0

5

10

15

20

25

30

M T W R F S S

Before

After

Capacity

Working with the Medical Staff to reorganize surgery schedules can have a significant impact on the smoothing of downstream demand as it did in this Ortho Unit.

Client Example

Demand Management in Orthopedics


Bed Availability (Policy):• Consistently applied process and definitions for applying ISO,

avoid and private status to patients • Defined policy for bed closures Consistent approach to status

clearing and communication• Preventive maintenance scheduled for low census timing• Clinical/Economic model for bed allocation

Best Practice: Bed Management/Patient Access

Bed Availability (Process):• Single consistent centrally managed and accountable front-end process for bed placement/room

assignment and bed closings due to ISO, “Avoid” and Private patient requirements• Clear responsibility and authority for patient flow and bed management – Single consistent centrally

managed and accountable front-end process for bed placement/room assignment, governance authority for the new “position” to be effective, clearly articulated relationships with key operational and clinical leadership, and conflict resolution process that involves and is supported by physician leadership.

• Commonly held decision rules as to patient placement steps, priorities and location• High census management process – Triggers to alert to approaching capacity thresholds and having

contingency response plans developed to put into play. Clearly defining and communicating the new policies, procedures and decision-making authority that goes into place during times of high census.

• Daily bed management meetings – Disciplined, daily bed management meetings (support with data, assure accountability); participants armed with governance authority to be make operational improvements; clearly articulated relationships with key operational and clinical leadership.

• Bed management/Patient Flow center – track bed (and other resource) capacity and utilization real-time throughout the institution. Often combined or adjacent to the nurse staffing office and/or admitting. Supported by new capacity management and/or capacity modeling information technology.

Communications


Discharge Planning

Entry Channels


Access

InpatientUnit

Operations



Bed Management/Patient Access

Supply: Available Med/Surg/ICU Beds

Unavailable Beds

On average116 beds (14%) are off-line and unavailable each day, with process inefficiencies responsible for 32% of off-line beds.

16 1032

8

748

13

864

M/S

/ICU

Bed

s in

Op

erat

ion

Mai

nte

nan

ce

Avo

ids

Iso

lati

on

Pri

vate

*

Sta

ffin

g/O

ther

To

tal

Ava

ilab

leB

eds

- 116 Beds37

Pro

cess

In

effi

cien

cy

* includes 13100 beds


• Unit staffing models constructed to reflect expected Admission/Discharge/ and Transfer activities with either:

−Dedicated A/D/T staff−A/D/T activity built into staff scheduling and

productivity ratios

• Shift scheduling organized to provide consistent coverage at peak A/D/T times

• Appropriate staff competencies and skill levels on key units

• Patient discharge status information accurately tracked and communicated in a consistent and timely manner

• Fully utilized physical capacity. Key areas include ED, PACU, OR, ICUs. Staffing to demand, expanded schedules, better utilized block times

• Case management models aligned with physician rounding and teaching model to enhance communications and better expedite patient discharge

• Nursing, transport and housekeeping consistently parse non-clinical patient discharge tasks

Best Practice: Inpatient Unit Operations

Communications


Discharge Planning

Entry Channels


Access

InpatientUnit

Operations



1. Development of a centralized “air traffic control” office that coordinated all bed requests and bed management related issues at an incremental cost of $150,000 annually to organization*

Inpatient Unit Operations

The solution set contained three fundamental changes.

InpatientAccessCenter

InpatientAccessCenter

StaffingShortage

Notification

BedClosure

Requests

BedRequests

Bed StatusChanges

ProcessBreakdowns

HighCensusLevels

• Authority to manage and enforce newly designed policies and processes

• Reduction in beds closed enabling organization to operate at higher census levels, absorb more volume and improve return on capital

• Reduction in patient placement times

−Increasing physician and employee satisfaction levels

−Promotes patient safety by more rapidly expediting care

• Monitor performance and intervene as appropriate

* Additional costs covered by revenue generated from volume increases

CASE STUDY


• Physician service acceptance and rounding processes are aligned with operational requirements of timely effective patient placement and discharge

• Efficient room turnaround process – “Red, yellow, green” bed availability notification system, restructured EVS priorities to make room turnaround a higher priority, restructured EVS management so there is a manager responsible for bed turnaround, SWAT team of EVS focused on bed turnaround, balancing EVS staffing with bed turnaround demand.

Best Practice: Patient Care/Support Processes

• Patient transport has consistent dispatch decision rules providing comprehensive coverage and agreed to prioritization, personnel tracking system to better utilize transport staff; disciplined, tiered level of personnel utilization, and zone concept of staff deployment.

• Diagnostic service requirements are flagged and expedited for pending discharge patients; reprioritized inpatient testing; matching staff to demand, and simplified ordering process.

• Infection Control actively manages ISO patient definition and clearing process• All support services staffing will be in alignment with ADT workload (e.g. EVS,

dispatch)

Communications


Discharge Planning

Entry Channels


Access

InpatientUnit

Operations



Patient Care/Support Processes – Managing Peak Times

Early AM: Peak bed demand

Day Shift: Peak Clinical Activity

Perfect Storm

Per

cen

t o

f T

ota

l

Perfect Bed Placement Storm

Source: BPIN

Late afternoon: Peak discharge period

Afternoon Shift Change - RN, Transport, etc

Inflow Outflow

0%

2%

4%

6%

8%

10%

12%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Admits Discharges Transfers

Peak Bed Demand

Inpatient Discharge Time vs. Admission TimeWeekdays


Best Practice: Discharge Planning

• Formal physician discharge process designed to facilitate earliest possible patient departure

• Resident and Attending rounding process scheduled and conducted to facilitate early discharge of patients

• Clinical/procedural activity schedules constructed with timely discharge facilitation in mind

• Clear unit-by-unit admit and discharge criteria, with supporting policies and procedures to make timely transfers happen

• Physician leadership on key units and overall process

• Discharge “lounge” for select discharged patients with prolonged departure waits

• Preferred partnerships with post-acute providers

• Rationalized and integrated approach to planning/facilitating patient transport from hospital to receiving facility/home

Communications


Discharge Planning

Entry Channels


Access

InpatientUnit

Operations



Best Practice: Info Management/Communications

• Cascading performance metrics – Key metrics to manage patient flow performance (e.g., average discharge time, bed turnaround time, patient discharge delays, OR room utilization, ED divert time, etc).

• Management process to manage to the new metrics – Cascading levels of bed management meetings. Using a rigorous approach to bed management meetings (support with data, assure accountability), with appropriate governance authority

• Visible, accurate, timely communications of bed status and changes

• Predictive volume model solutions – These models range in complexity from simple PC-based solutions using standard database software to sophisticated process simulation software packages.Real-time patient tracking model – Simple database that tracks capacity and demand real-time.Patient flow weekly forecasting model – Database that includes projected daily demand (from

OR, ED, Admitting etc.) and historical data (ALOS, patient routing and service mix etc.). Used to forecast what capacity will be over the next 7 days.

End-to-end process simulations – Simulation software that include detailed process characteristics (patient arrival times frequency, distributions, routings, case times, ALOS, staff and equipment resources etc.). Used to run multiple “what-if” scenarios.

• Staff availability notification systems – Paging or call systems that track staff location and activity, and are used to “message” new task orders.

Communications


Discharge Planning

Entry Channels


Access

InpatientUnit

Operations



Best Practice: PACE Management Performance Dashboard

Entry Channels

BedManagement

I/P UnitOperations

Pt Care andSupport

1. # Pts Waiting for Beds

• ED• Admit Office• Direct Admit

Unit2. Wait Times

• ED• Admit Office• Direct Admit

Unit3. ED AMA Rate4. Hrs ED on Divert5. ED Admit

Decision to Bed

1. Admissions2. ADC

• Overall• ICUs• Key Units

3. Occupancy• Overall• ICUs• Key Units

4. # of Beds Closed

5. Occupancy Efficiency (Midnight/ noon census)

1. Acute ALOS2. Medicare

ALOS3. Percent

Travelers & Agency staff

4. Percent of patients that are “long-stay”

1. I/P Room Turnaround Time (TAT)

• Total• Request• Turn

2. Patient Transport Time

• Total• Request• Transport

3. OR Room TAT

Discharge Planning 1. % Discharges by 11:00 AM 2. Percent Avoidable Days

Metrics in red reviewed daily by COO


•Leadership must drive the PACE redesign and process:

−At the outset leadership and medical staff must have

»a thorough understanding and agreement regarding the goals and expected outcomes of the effort

»agreement regarding the process, the outcomes, the data and the analyses in order to avoid endless refinement of data

−Communication should be frequent and consistent

•Staff should design the new PACE process

–Staff have developed a deep understanding of the existing process and the many work- arounds required to make it work today. Their knowledge will ensure the new PACE design will function best

•Data should inform the design process

−Benchmarking must be able to identify the best practices driving performance differences and assess whether such best practices are applicable to the organization

−Availability of credible internal data and information enables the discussion to focus on outcomes rather than accuracy of data

•Leadership must drive the PACE redesign and process:

−At the outset leadership and medical staff must have

»a thorough understanding and agreement regarding the goals and expected outcomes of the effort

»agreement regarding the process, the outcomes, the data and the analyses in order to avoid endless refinement of data

−Communication should be frequent and consistent

•Staff should design the new PACE process

–Staff have developed a deep understanding of the existing process and the many work- arounds required to make it work today. Their knowledge will ensure the new PACE design will function best

•Data should inform the design process

−Benchmarking must be able to identify the best practices driving performance differences and assess whether such best practices are applicable to the organization

−Availability of credible internal data and information enables the discussion to focus on outcomes rather than accuracy of data

Approach to Improving PACE PerformanceThe Chartis Group follows several principles in designing an approach to improving PACE performance.


In Chartis’ experience, some success factors have been consistent throughout our successful PACE redesign engagements.

•Look at everything from the patient’s perspective

•Make it a strategic priority

−Active, aligned and ongoing executive and physician commitment and accountability

•Reconstruct and manage processes end-to-end around a specific set of target outcomes and guiding principles

• Invest in infrastructure:

−Information systems and technology

−A/D/T management personnel

•Develop aggressive, collaborative and coordinated patient placement policies and processes

•Establish tools, measures and culture to support effective patient access and bed management

•Look at everything from the patient’s perspective

•Make it a strategic priority

−Active, aligned and ongoing executive and physician commitment and accountability

•Reconstruct and manage processes end-to-end around a specific set of target outcomes and guiding principles

• Invest in infrastructure:

−Information systems and technology

−A/D/T management personnel

•Develop aggressive, collaborative and coordinated patient placement policies and processes

•Establish tools, measures and culture to support effective patient access and bed management

Approach to Improving PACE Performance - Critical Success Factors

boston chicago new york san francisco september 20th, 2005 maryland association of healthcare...

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