Patient Safety Summit Throughput- Led Initiatives with EPIC Source Data January 8, 2014

1. Patient Safety Summit Throughput- Led Initiatives with EPIC Source Data January 8, 2014 Judy Shepard, RN, MN Director, Quality/ Bed Management Raymond Smith, MBA Director, Clinical Decision Support

2. Conflict of Interest Disclosure Raymond Smith, MBA Judy Shepard, RN, MN Has no real or apparent conflicts of interest to report.

3. Learning Objectives • Learn how Grady used the EPIC system to improve patient throughput and communication to allow inter-professional collaboration towards a strategic goal- improving patient care. • Hear how analysis exercises through LEAN/ Six Sigma can be used to convey and reinforce key concepts in quality improvement. • Assess the theory behind sampling strategies and the necessity of applying appropriate statistical techniques to analyze EPIC data and make valid inferences. • Learn tips for improving EMR adoption at the staff level. • Review methods for providing process improvement initiatives to reduce turnaround times and optimize patient throughput efficiency.

4. Grady Health System, Atlanta Georgia • Level 1 Trauma Center in the center of the city of Atlanta • Premier Regional Academic Medical center with two schools of medicine (Emory and Morehouse) • Operating at capacity with need to grow • 953 licensed beds; 26,000 admissions • 22 Hospital based Specialty services and • 6 NHC, nearly 620,000 patient visits • Including 300,000 Emergency visits • 4800 employees; 1000 physicians

5. Our Challenge • Decrease the average LOS in the ED from median of 7.0 hours in 2012 to 6.0 hours in 2013 • Decrease door to provider time in the ED from 2.4 hours in 2012 to 1.75 hours in 2013 • Decrease LWBS rate in the ED from 30% in 2012 to 15% in 2013 • Improve efficiency in processing time from decision to admit in ED to patient placement in bed. 3 hours in 2012.

6. Current ECC

8. QI Perspective

9. Why does Workflow Matter? • Understanding of “How We Care for Patients” • “Physiology” as well as “Pathophysiology” of a health care delivery system • Necessary to Improve the Quality of Patient Care • Fundamental to achieving desired Quality Outcomes (IOM): • Safe, Timely, Effective, Efficient, Patient-centered • “Lack of knowledge... that is the problem… if you can't describe what you are doing (as a process), you don't know what you're doing.” –W. Edwards Deming • Impacts Facility, Process, and IT Design, as well as Training, Policy, and Culture: • Must understand in order to optimally manage and improve • Critical to avoiding Unintended Adverse Consequences • IT Systems must integrate into and facilitate optimal workflow Stead IOM/NAE (2009), Karsh AHRQ (2009) • Checklist Manifesto • Volume and complexity of knowledge has exceeded our ability to deliver quality consistently without a simple tool- the checklist

10. Global View of Patient Throughput Intake Inpatient Care Disposition • Perioperative Services • Improved OR prep for day of surgery • Improved start of day activities • Improved start and TAT • Develop case scheduling process • Case Mgmt • Prioritize discharges • Coordinate with Nursing/Physicians • Long stay patient placement • Family communication • Diagnostic Testing • Timely TAT • Scheduled inpatient testing • Emergency Department • Initiation of rapid care protocols • Streamlined triage processes • Bed-side registration • Bed Management • Anticipatory planning for beds • Coordination with Case Manager for discharges • Global view of all beds • Physician champion to facilitate • timely discharge Effective Patient Throughput • Environmental Services • Coordination with BedMgmt and Nursing to match demand • Day of Discharge • Communication with family • Nursing/Case Manager/Social Worker support at the discharge • Notification of dirty bed • Timely bed turnaround • MD Coverage • Timely discharge order • Coordination with Case Manager/ • Social Worker Admissions • Direct Admissions from • Clinics • Screening for appropriateness • Avoid direct admissions going • to the ED • Guest Services • Coordination with Nursing and ED • ICU/Step-down/ • Telemetry • Facilitation of patient transfers • Placement of Long Stay patients • Nursing Units • Coordinate with Case Mgmt • Point person for facilitation of flow • Initiation of bed cleaning • External Facility Transfers • Screening for appropriateness • Requires financial clearance Information Systems • ECIN • Invision Global View of Patient Throughput Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 2

11. Six Sigma DMAIC Methodology and CDS Tools (fact based decision making) Deliverables

12. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

13. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

14. 20,649 cases reviewed Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

16. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

17. + Skills- underutilized talent Focus of Lean: Elimination of Waste

18. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

19. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

20. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

21. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

22. Throughput Patient Flow Initiatives for PI • Team assessment pull process- ICU admissions • Increase utilization of the Discharge Lounge • Preliminary Discharges the day before • Capacity plan to admit high volume/ peak time admissions • Enhanced communication between Attending/Residents • Increase mid-level (s) at peak times of ED volumes • Step Down Criteria for Flow/Placement Optimization

23. Quality/ Performance Improvement2013 Recommendations

24. Bed Management Model RN Bed Czar The dedicated RN Bed Czar has an overview of all beds at all times and addresses any challenges in bed placement, plans proactively for the next day and works with Nursing, PACU, Case Management, ED, Admissions, Guest Services, Housekeeping, Physicians, etc., to appropriately place patients. Source of Admission ED PACU, Cath Lab, other procedure areas Direct admissions from clinics and transfers from other hospitals ED CM performs clinical review for appropriateness of admission. Unit Secretary notifies Admissions of bed need. Each area notifies Admissions of bed need via system ~ 1 hr. prior to bed needed Physician/designee calls admissions CM with patient clinical information and discusses plan of care Admissions CM performs clinical review for appropriateness of admission Admissions CM Charge RN or Unit Designee Admissions Admissions evaluates bed board and places patient in appropriate bed. Admissions notifies Charge RN of admission. Charge Nurse calls back within 10 minutes with final clean bed assignment on the unit. Financial screening performed by PAR Patient Access Pages charge RN/designee w/ bed assignment. Direct admissions from clinics and transfers from other hospitals PACU, Cath Lab, other procedure areas Report automated/faxed. Receipt of report verified and questions answered. Patient transferred w/i 30 min ED Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 9

26. Insights and Lessons Learned • Must include Direct Observation, Record • Don’t forget the Clinical dimension • Repurpose Data currently in environment • Consider Multiple Methods • Focus on time or resource consuming tasks • Don’t miss Rare or Critical events, interruptions, workarounds, or delays • Simulations force detailed descriptions of work and are good for communicating with subjects and testing interventions or scenarios • Consider all “Systems”, their respective “Lifecycle” state, and Contextual Factors • Need for a Systematic, Interdisciplinary Approach to study workflow • Engage Leadership and Staff

27. Thank You Questions???