Clinical Safety & Effectiveness Session # 11

1. Clinical Safety & Effectiveness Session # 11 Emergency Center Observation Unit 10.15.09 DATE

2. Project Team • Richard A. Ivey • Quality Engineer, Office of Performance Improvement • Cindy Segal • Clinical Quality Improvement Consultant, Office of Performance Improvement • Cylette R. Willis, PhD • Associate Director, Quality Education and Evaluation, Office of Performance Improvement • Patrick Chaftari, MD Assistant Professor , GIM, AT & EC • Jean H Tayar, MD Assistant Professor, GIM, AT & EC • Ashutosh Gupta Clinical Business Manager, EC Project Sponsor: Carmen E. Gonzalez, MD Associate Professor, GIM, AT and EC Section Chief, EC

3. Improving Patient Care in the EC

4. EC Situation • National benchmark ER Length of Stay (LOS) is 4 hours • MDACC EC LOS averages 9.5 hours (up to 24 hrs ) • Current situation affects patient care and safety

5. Can We Improve This Picture? Patient safety Patient care Patient satisfaction Bed utilization

6. Pts Treated while in The EC (No Inpt Admission) 20+ Hrs, N= 675 16-20 Hrs, 6% N=642 6% 11-15 Hrs, N=1,328 00-05 Hrs, 12% N=4,734 42% 06-10 Hrs, N=3,879 34% Patients Treated While in EC (No Admission) % of Visits by Hours in EC from Lobby Sign-In to Leave Time April 1, 2008 to March 31, 2009 1 year Data Prepared by: Linda DeFord OPI Clinical Informatics Data Source: EC Tracking Data

7. 20+ Hrs N= 675 16-20 Hrs 6% N=642 6% Snapshot of Patients Discharged from EC After a LOS > 16 hrs (4) 3% (14) 12% (27) 23% (74) 62% (March 2009, 119 pts) One year data

8. EC Patient Process

9. OBS Unit Better Care • Opportunity to improve patient safety and patient care • Literature review: Placement on OBS will improve quality of care and revenue • Improve disposition→ clinical outcome→ decrease liability • Decrease patient and caregiver frustrations • Free up EC bed →Decrease some of the EC congestion →Shortens LOS • Decrease cost by efficient usage of EC and inpatient bed • Avoid unnecessary admissions and decrease un-reimbursed readmissions

10. Observation Unit • Observation unit could be → a safe → effective → cost-saving way of ensuring that patients who are considered to be intermediate category receives appropriate care.

11. Project

12. AIM Statement • Baseline period: May 2008 - April 2009 • Process begins when provider evaluates patient in EC and ends when provider places patient on Observation • Value to the organization – improve patient care and safety, potential financial advantage The aim of this project is to increase the percentage of EC patients placed on Observation by 50% from the baseline of 1.95% to 2.93% during the pilot period, July 1 - July 22, 2009.

13. How Will We Know That a Change is an Improvement? Outcome measure: Percentage of EC patients placed on Observation Data collection: Whiteboard activity report Technical charges Specific target: 2.93%

14. Project Milestones • Team created April 2009 • AIM statement created April 2009 • Weekly team meetings May - August • Planning April - June • Interventions implemented July 1 – 22 • Presentation August 7

15. Appropriate forms Physician hand-off Fishbone Diagram Physicians Nurses Clerks Don’t think about it Training Training Staffing Lack of education Data entry Paperwork Do not understand billing Do not check observation box on charge sheet Guidelines for disposition decision Confirm access to CARE system Do not notify clerks that patient placed on Observation Lack criteria to place on Observation LOW NUMBER OF PATIENTS PLACED ON OBSERVATION Unclear processes Whiteboard does not visually identify current Observation patients Lack of space Order sets Identifying Observation patients Budget to staff space Tracking patient progression Tracking LOS countdown Technology Facilities Processes

16. PLAN: The Intervention • Plan project • Develop presentation materials for providers • Design new EC physician order set and forms • Start general guidelines for placing patients on Observation • Gain leadership buy-in • Raise awareness of OBS availability

17. Observation Placement Form Placeholder for Obs form and/or physician order set visual

18. DO: Implement the Changes April – June: Build awareness (soft implementation) July 1: Implement interventions July 1 – 22: Measure outcomes July 1 July 2 July 3 July 4 July 5 July 6 July 7 July 8 Conduct kickoff Implement order sets Post order sets online Place poster in EC

19. EC Observation start date: July 1st,09 Upon completion of the patient’s work-up

20. Implementation Issues • Stakeholder identification was incomplete (Clinical Effectiveness) → Delay in posting physician order set • Implementation period was too short to address EC meeting schedule, introduce language and new forms • Non-EC faculty working in the EC not familiar with the process

21. Results

22. CHECK: Results and Impact Test of proportions p-value < 0.001

23. Before/After Intervention Test of Means, p-value = 0.004 Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

24. Before/After Intervention Test of Means, p-value = 0.002 Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

25. Potential Financial Impact • What is the financial impact of these results on the organization? • Decrease waste by more efficient use of EC bed and inpatients beds • Capture of uncharged technical and professional fees • Bed utilization and resources

26. $650,000 Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

27. Assuming 62% of patients with EC stay > 16 hours and discharged home were placed on obs, this represents a potential benefit of approximately $428,000 Data source: EC Whiteboard (May '08 - Apr '09) To estimate the charges for patients with EC stay > 16 hours, an average approach was used using Levels 4 and 5 charge amounts ‘Obs – 1 provider’ assumes that the EC provider is caring for the obs patient ‘Obs – 2 providers’ assumes that a non-EC provider is caring for the obs patient Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

28. Annual Cost • FTE is based on the assumption that the Observation unit will be operational 24/7 • Personnel Cost is based on new staff with less than 1 year at M.D. Anderson • Medical supplies/expense = 4% of Total EC Medical supplies • Deduction % = 48.67

29. Estimated Number of Observation Beds

30. The 'Utilization of Obs Beds' is calculated as the average amount of time occupied divided by the total time available (24-7). This is done by looking at each of the dedicated beds over the entire year. The choice of number of obs beds should be balanced with the number of patients waiting for a bed Source: EC Whiteboard Prepared By: Richard Ivey

31. Next Steps

32. ACT: Expansion of Implementation • Maintain and expand awareness of available OBS services in the EC • Improve identification of OBS patients in the EC • Review appropriate use of OBS placement • Track progress of revenue realization

33. Conclusions • OBS unit could be a viable solution to improve patient safety and quality of care in the EC • By decreasing waste and capturing uncharged services OBS unit may provide net revenue to organization

34. Recommendations • Designated OBS Unit (Closed unit) • Access limited to EC provider and/or observation provider • “Virtual” or “Shared” OBS unit within Pod A • Designated non-EC provider coverage • Improve safety and quality of patient care • Cost of additional provider offset by fee structure

35. What have we accomplished so far? • Increased number of observation patients to 5.57% • Improved patient safety • Medication reconciliation • Diet, activity, fluid infusion • Improved quality of care • Better oversight by having an APN following these patients on OBS • Increased RN satisfaction and confidence • Improving communication about plan of care

36. Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

37. Questions Thank you