Patient Access and Capacity Enhancement PACE

1
University of Maryland Medical Center

• Patient Access and Capacity Enhancement PACE

Michael Harrington, MBA Director Patient Access
2
University of Maryland Medical SystemUniversity
of Maryland Medical Center

• System and Medical Center Overview

3
University of Maryland Medical System
System Overview
The University of Maryland Medical System (UMMS)
is governed by a board of directors and is
neither owned by the State of Maryland nor
governed by the University of Maryland. The
University of Maryland Medical Center (UMMC) is
the Systems academic medical center serving the
region and Baltimore City with a full continuum
of services. UniversityCARE is a partnership
between UMMC and University Physicians, Inc.
operating primary care centers in West Baltimore
and multispecialty satellites.
University of Maryland, Baltimore
Board of Directors
University of Maryland Medical System
Professional Schools
Community Hospital Group Baltimore Washington
Medical Center Maryland General
Hospital Kernan Hospital Mt. Washington
Pediatric Hospital Shore Health
System Memorial Hospital at Easton Dorchester
General Hospital
University of Maryland Medical Center

University Hospital
Greenebaum Cancer Center
Shock Trauma Center
University Physicians, Inc. Faculty Practice Plan
University Specialty Hospital
Programmatic Joint Ventures
UniversityCARE, LLC
4
University of Maryland Medical Center
General Founded in 1823 as the Baltimore
Infirmary, the University of Maryland Medical
Center is one of the nation's oldest teaching
hospitals. Located on the west side of downtown
Baltimore, the Medical Center provides highly
specialized tertiary and quaternary care for the
entire state and region and comprehensive care
for the West Baltimore community. UMMC provides
a broad range of inpatient and outpatient
services and functions as the primary teaching
hospital for three graduate schools of the
University System of Maryland. Medical
Staff All members of the medical staff at UMMC
are members of the faculty of the School of
Medicine or the School of Dentistry. The
majority of the active admitters to UMMC are
salaried full-time faculty of these schools. As
of June 2005, there were 1,082 clinical faculty
on the medical staff, and approximately 79 of
whom were Board certified. Services
Provided UMMC offers a broad range of primary,
secondary, tertiary and quaternary services
complemented by extensive education and research
activities. In addition to meeting the medical
needs of its immediate service area, UMMC serves
as a tertiary and quaternary referral center for
the State and Mid-Atlantic region and considers
itself a national leader in the following
specialties solid organ transplantation, bone
marrow transplantation, trauma care, cardiac
care, oncology, neonatal and high risk
obstetrics, and innovative laparoscopic surgery.

• University Hospital
• UM Marlene and Stewart Greenebaum Cancer Ctr
• R Adams Cowley Shock Trauma Ctr
• UM Hospital for Children
• 5,250 Employees
• 665 Licensed Beds
• Located in Baltimore City
• 33,500 admissions
• 523 ADC
• 5.9 ALOS
• 165,000 outpatient visits
• 18,000 Surgeries
• 62,000 ER Visits

5
UMMCs Patient Access and Capacity Challenge
Initial Situation

• Wide swings in average daily census (low on the
  weekends, peaking Tuesday/Wednesday/Thursday)
• Lost admissions experienced daily by physicians
  attempting to bring in patients via ExpressCare
• Hourly mismatch between bed demand and bed supply
  until at least 6pm
• Frequent holding patients in key access points,
  including the ED and OR / PACU
• Daily shifting of patients in order to find
  capacity for admissions
• Significant physician, staff and patient
  frustration with patient flow
• Clinical services are often managing patient
  flow in order to ensure bed availability for
  their patients
• Additional bed capacity coming on line over the
  next 18 months
• Planned physician recruitment, particularly in
  surgical areas, expected to exacerbate the bed
  crunch

6
PACE Patient Access and Capacity Enhancement
PACE imparts equal focus on addressing the supply
of available beds and the processes that impact
the demand for patient beds.
Key Drivers of PACE Improvement
Outcomes
Results

• Practices and Policies
• Bed Allocation
• Scheduling

• Intake efficiency
• Discharge and Bed Turnaround

7
PACE Process Framework
Means of Access
Bed Management And Patient Placement
Inpatient Unit Operations
Pt.Care and Support Processes
Patient/Bed Aggregation Case Management Staffing S
cheduling Information Collection
Physician Practices Procedural and Ancillary
Services Diagnostics Environmental
Services Infection Control
Bed Management Policy Bed Management Processes
and Practices Patient Entry Processes Patient
Placement Processes and Practices
Discharge Planning
Communications
Data, Information and Measures
8
PACE Assessment Executive Summary
Means of Access

• UMMC averages 100 admissions during the week
  drops to 60 on the weekend
• ED flow significantly impacted by Medicine Cap
  and a lack of an overflow mechanism to accept
  patients once the cap is met current ED length
  of stay for IP admission is 10 12 hours
• OR flow impeded by lack of surgical beds with
  patients frequently boarding overnight in the
  PACU
• ExpressCare experiencing lost admissions for all
  services approx 30 40 admits per month -
  usually due to a lack of ICU / IMC beds

Entry Channel 3 (e.g. Multiple Others)
9
PACE Assessment Executive Summary

• No one person has knowledge of the entire bed
  base at any given time
• Operations Center manages approximately 37 of
  the bed base only
• Guidelines and prioritization criteria for
  managing the bed base during peak times lack
  clarity and / or do not exist
• Clinicians and other staff can veto an admission
  or transfer at any point in the process 1000
  points of no
• Significant distrust of bed management process
  due to lack of real-time information and unclear
  decision-making procedures

10
PACE Assessment Executive Summary

• Scope of Case Manager role limits the amount of
  time and effort devoted to coordination care and
  facilitating patient flow
• Nurse staffing under pressure on a daily basis
  due to staff calling in
• Nurse Coordinators focus a significant amount of
  effort on solving staffing shortages during the
  day, limiting the overall amount of time spent on
  managing beds and patient flow
• No one person on unit responsible for managing
  patient flow current charge nurse often takes
  an assignment
• Operations Center staffing is thin, given the
  lack of IT infrastructure and the size of the bed
  base

11
PACE Assessment Executive Summary

• Inconsistent physician rounding practices limit
  the organizations ability to facilitate early
  identification of discharges
• Discharge order and discharge summary frequently
  completed late morning or in the afternoon
  delaying the start of the discharge / room
  turnaround process
• Strong perception of a 5 day hospital difficult
  to obtain certain services on the weekend
• Staffing model for Environmental Services can
  lead to lengthy delays in room turnaround
  appox. 3.5 hours from when patient leaves the
  room to when the room is available
• Only 20 of eligible patient discharge transports
  are being done by the Transport team results in
  nurses leaving the floor

12
PACE Assessment Executive Summary

• Current bed management application used by
  Environmental Services and Transport only
• Nurse Coordinators maintain a mental picture of
  the bed base do not use bed management
  application due to perception of functionality
  limitations
• Communications between Operations Center and
  patient care areas heavily dependent on telephone
  (as opposed to automated communications
  processes) resulting in multiple phone calls to
  resolve individual issues
• Although discharge planning is a high priority
  for Case Management, it is one of many priorities
  which impacts the timeliness of planning
  activities
• While the organization collects a significant
  amount of data, it is not always distributed to
  the relevant individuals
• The amount of data distributed is voluminous
  and accountability for acting upon data is
  frequently unclear

13
PACE Objectives

• Centralized bed management.
• Real-time, accurate, and accessible knowledge of
  the bed-base and bed status.
• Clear processes that support effective patient
  placement and awareness of the bed-base.
• Effectively structured facilities management,
  patient transportation, and bed cleaning
  processes for rapid room turnover and room
  readiness.
• Physician and nursing partnerships to facilitate
  patient throughput.
• Clear criteria for patient admission/discharge
  and a consistent, outcomes-based rounding
  process.
• Charge Nurse with clear responsibilities for
  patient flow.
• Case Management focused on removing flow
  barriers. Identifies and communicates pending
  discharges to Patient Placement Center.

14
Patient Placement Center Design
Values
Accessibility Clarity Objectivity
Transparency
TRUST
Integrity
Respect
Consistency Criteria Responsibility
Courtesy Honesty Positivity
15
Patient Placement Center Design
Mission and Primary Responsibilities

• Meeting the bed access needs of our patients and
  our referring and admitting physicians
• Getting patients into the most appropriate care
  settings in an expeditious manner
• Ensuring maximum bed availability, particularly
  during periods of peak demand
• Managing all incoming bed requests and bed
  assignments
• Coordinating service acceptance for admitted
  patients
• Managing the UMMC bed base - openings and
  closures
• Staying aware of current and projected patient
  flow (incoming and outgoing)
• Keeping patients, physicians and referring
  institutions apprised of bed availability status
• Escalating issues to the appropriate parties when
  process breakdowns occur

Mission
Primary Responsibilities
16
Patient Placement Center Design
Facility Design
Prior State

• Treated as back office
• Space small, cramped, hand-me-down furniture, in
  basement.
• Bed management, staffing and nurse supervisor all
  functions of role
• Manages 37 hospital beds
• Create space that is accessible and prominent
• Separate roles of bed management, staffing and
  nurse supervisor
• All beds managed through the PPC

Redesign
17
Patient Placement Center Design
Staffing Design
Prior State

• 2 coordinators on day shift, one night and
  weekends
• On dayshift one coordinator responsible for
  patient flow the other for staffing and patient
  placement
• Nightshift weekend role has 3 functions
• Patient flow, staffing, in-house administrator
• Manager reports to CNO
• 4 coordinators on dayshift, 2 nightshift and one
  on weekends (soon to add another)
• Additional coordinators focused on mission
  critical product lines
• Separate functions on in-house administrator and
  staffing.
• Additional Director reports to CMO

Redesign
18
Patient Placement Process
Trigger Points
Staffing Shortage Notification
Bed Closure Requests
Bed Requests (mode)
(from Nursing Directors)

• Isolation
• Privates
• Avoids
• PM
• Maintenance
• Staffing
• VIPs

• ED (FirstNet)
• MEC (resv. log)
• MD Offices (resv. log)
• OR schedule (resv. log)
• Procedural (resv. Log and phone calls)
• Inter-hospital xfers (resv. log)
• Internal xfers (faxed lists and phone calls)

Patient Placement Center
Most closure actions require approval from
Patient Placement Center
Status Changes
High Census Levels
Process Breakdowns

• Maintenance
• Isolation
• Housekeeping

• Refusal to accept patients
• Unauthorized bed closures

19
Patient Placement Center Design
PPC Roles and Responsibilities
Bed Coordinator

• Coordinate patient flow and bed utilization with
  charge nurses and nurse practitioners
• Facilitate issue resolution with medical
  directors and Chief Medical Officer when
  conflicts arise
• Place patients in appropriate beds, based on
  admission criteria where applicable, and bed
  availability
• Review surgery schedule and PACU boarders in
  order to interpret and communicate demand to
  appropriate units
• Review ED reservation list and determine
  appropriate placement based on current and future
  bed demand
• Facilitate critical transports and liaison with
  ExpressCare in order to evaluate daily demand
  from external hospitals and make patient
  placements when appropriate
• Review admission requests from other access
  points and determine appropriate placement
• Evaluate current and future bed supply to
  anticipate areas of congestion and potential
  obstacles to patient flow
• Disaster preparedness and coordination

20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
Daily Capacity Report
24
Communication and Change Management
Town hall meetings

• Series of Town hall meetings hosted by the CMO
  CNO
• All staff strongly encouraged to attend including
  patient care, ancillary and physicians.
• Along with information about PACE, the following
  messages were emphasized
• All requests must come through the Patient
  Placement Center
• UMMC owns the beds.
• A clean staffed bed is an open bed.
• Only the PPC can close a bed. Any decision to
  close a bed must be made at the director level
  and include a nurse and physician.
• Clinical criteria and unit competencies will
  drive patient placement and cross boarding
  options.
• Patients receive better care in our beds than
  waiting at home, being in another facility or
  driving around in an ambulance.

25
PACE Project Essentials
Adopted Principles from Six Sigma, Lean, PDCA

• Leadership involvement and support
• Implementation of an executive oversight
  committee attended by the CEO, physician and
  nursing leadership.
• Hospital-wide participation
• Implementation teams with physician and hospital
  administrative co-leaders.
• Attendance from patient care and support services
  
• Let the data do the talking
• Process analysis
• Pareto
• Brainstorming
• Surveys, etc

26
Patient Placement Center Design
Sub-Process Room Turnaround / Bed Ready
Discharge Process
Turnaround Process
H-keep Notify
Patient Out
H-keep Finish
Bed Ready
STAR
H-keep Arrive
Cerner
Decision
Order
Summary
930
1221
1142
100
132
425
137
128
415
342
5
2
1
3
Not drawn to scale
6
4
7
8
Decision to Discharge to Patient Departure 330
(HHMM) Decision to Discharge to Discharge
Summary Written 212 Decision to Discharge to
Discharge Order Written 251 Patient Departure to
Discharge Entered into PowerChart 028 Housekeepin
g Notification by Unit Secretary 032 PowerChart
to info transcribed into STAR 009 Housekeeping
Notified to Housekeeping Arrived 210 Patient
Departs to Bed Ready 325
1
2
3
4
5
6
7
8
27
Room Turnaround / Bed Ready Analysis
Housekeeping Impact

• Results
• Average 202, Median 210.
• Staffing model not aligned with typical patient
  departure timing.

28
Room Turnaround / Bed Ready Analysis
Total Turn Around

• Results
• Average 317, Median 325

29
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Telephony
Patient departs room
Admitting DC in STAR
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
30
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Patient departs room
Admitting DC in STAR
Telephony
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
31
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Telephony
Patient departs room
Admitting DC in STAR
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
32
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Telephony
Patient departs room
Admitting DC in STAR
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
33
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Telephony
Patient departs room
Admitting DC in STAR
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
34
Room Turnover
Room Clean
Via Transport
Bed Status in Teletracking
Telephony
Patient departs room
Admitting DC in STAR
Via Nurse or PCT
Notification to Housekeeping
Nursing PC order to Admitting
Nurse or Unit Secretary
Room Clean
Patient Departure
Registration
35
Bed discrepancies due to lag-time
36
Room Turnover
Sub-Processes Bed Turnaround / Bed Ready
Process Definitions

• All eligible transfers and discharges will be
  transported via Patient Transport
• Patient Transporters will initiate the bed
  turnaround process by communicating patient
  departure to PPC and EVS
• PPC prioritizes the order in which rooms are
  cleaned
• Facilitation of the bed turn around process is
  the responsibility of the Charge Nurse, EVS
  Supervisor and PPC
• Multiple / competing demands for room turn around
  are prioritized by the PPC based upon defined
  criteria
• PPC declares a bed ready for use a clean bed is
  a ready bed
• Case Management communicates pending discharges
  with approximate discharge times to PPC to ensure
  knowledge of potentially available beds

37
Room Turnover
Sub-Processes Bed Turnaround / Bed Ready
Process Recommendations Bed Turnaround
Prioritization

• Base level prioritization of bed cleaning
• Pending beds in order of wait time
• Prioritization during peak time / competing
  demands
• PPC prioritizes order of room cleaning for EVS
  based on
• Patient acuity
• Patient flow requirements (Bed Coordinator to
  assess flow bottlenecks and develop strategy)
• PACU decompression
• ED decompression
• ICU / IMC decompression
• Patient wait times
• PPC discusses prioritization with EVS supervisor
  and nurse managers / charge nurses on affected
  floors

38
Role of the Charge Nurse and Medical Director

• Timely patient placement in/out of the unit
• Easily Identifiable and Highly Visible
• Central point of contact for PPC, case
  management, physicians, etc.
• Facilitate Transport and Environmental services
  for timely room turnover
• Coordinate patient acuity with nursing compliment
  experience to maintain bed-base and safe patient
  care environment
• Liaison with colleagues to help facilitate
  patient flow and discharge panning
• Function as arbitrator when issues arise
• point of contact at times of high occupancy

39
Patient Placement Center Design
Daily Bed Meeting
Prior State

• Information sharing
• Census
• Discharges
• Staffing needs
• Problem-solving
• All information regarding admissions, transfers,
  discharges, closed beds and staffing needs to be
  communicated to PPC prior to 9am.
• PPC compiles and distributes Capacity Report at
  meeting
• Affirmation of content of report.
• Identification of potential bottlenecks
• Declare strategy
• Afternoon meeting to discuss next day.

Redesign
40
Lost Admissions Review

• Weekly MM style review
• Attended by MEC and PPC
• ExpressCare responsible for maintaining
  communication log
• PPC responsible for situational description
• Units presented census, pending admits,
  transfers, d/cs (24/29, 2 beds closed due to
  staffing, 2 pending admissions from ED)
• Determine factors that contributed to lost
  admission.
• Identify and implement action items.
• Weekly report to CMO/CNO and medical directors.

41
Sub-Processes Bed Request / Bed Assignment
Process Flow ExpressCare / Direct Admit to
Inpatient Bed
42
UMMC Volumes
ExpressCare Admission Rate
UMMC Inpatient Admissions
OR Volumes
ER Admissions
43
Variance Metrics
44
Patient Placement Center Design
External Model Evaluation Barnes-Jewish Hospital

• Improving effectiveness of bed management process
  is a complex endeavor that requires
  prioritization and sequencing of initiatives
• BJH began with the Patient Placement Center
• On going efforts to improve process continue
  after 2.5 years
• Entire organization is uniformly focused on PACE
• Instrumental step in improving process is to lock
  down the bed base agree on the number of
  operational beds
• Real-time knowledge of bed status integral to
  improving patient flow enabled by a bed
  management application

45
Patient Placement Center Design
External Model Evaluation Barnes-Jewish Hospital

• PPC has sole authority to make placement
  decisions and close beds PPC does not ask for
  permission to use a bed
• Physician champion plays a key role as an arbiter
  when competing demands for beds arise
• Significant investment required in patient care
  to continue improvements after implementation of
  PPC
• Free charge nurse role (no patient load from
  7am-7pm)
• Improved nurse-patient ratios
• Geographic coverage model for Medicine
• Case Management role focused on coordination of
  care