262 The Patient Experience from A-Z: From Emergency Room to Inpatient to Discharge

1. 262 The Patient Experience from A-Z:From Emergency Room to Inpatient to Discharge Presented by Gail Edwards RN CAC Peter Woodbridge MD, MBA

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3. 3 CPRS and Inpatient Quality and Flow Peter A. Woodbridge, MD, MBA ACOS for Quality & Clinical Informatics Roudebush VAMC Indianapolis, IN

4. 4 What is an Error?

5. 5 Understanding Human Error Cognitive Processing Skill-based: Familiar, automatic procedural tasks Rule-based: Tasks approached by pattern-matching from a set of internal problem-solving rules Knowledge-based: Tasks approached by reasoning from first principles Human Error Types Slips: Incorrect execution of a planned action Lapses: Omission of a planned action Mistakes: The plan is not suitable for achieving the desired goal

6. 6 Factors that Contribute to Human Errors Disruptions / interruptions Execution of plan is interrupted Misinterpreted cues Errors of association (�you see what you intended�) Variance Actions required do not precisely match internal cognitive pattern Improper cues Cue suggests the incorrect action is required Invisible cues The cue for action is not visible (a problem with automation) Complexity Increased cognitive strain

7. 7 What is Reliability? Technical definition �The capacity of a device or system to perform as designed� �The resistance to failure of a device or system� �The ability of a device or system to perform a required function under stated conditions for a specified period of time� Reliable method It is �owned� by the workgroup Everyone follows it It is deliberately developed It is written down It is the foundation for improvement

8. 8 Creating Reliability �Good� (10-1) Vigilance Common equipment Personal check lists Working harder next time Education Awareness Compliance feedback Standard order sets �Great� (10-2) Standardized Work Decision aids Reminders Desired action = default Opt-out versus opt-in Automate scheduling of tasks Forcing functions Redundancy

9. 9 Reliability & Variability A reliable process generates predictable outcomes Predictability and variability move in opposite directions

10. 10 Consequence of Unreliability Tolerance for ambiguity What is the goal? Who is responsible? How do we exchange information and services? Precisely how do we do the task? Ambiguity ? Workarounds Workarounds ? Errors & Stress

11. 11 The Quality / Reliability Challenge Transforming the organizational culture from one of tolerance of ambiguity and workarounds to one where: Staff strive continuously to eliminate ambiguity Problems are addressed when they occur through rapid cycle change (RCC) experimentation Improvement is measured and decisions are data driven Solutions are disseminated adaptively through collaborative experimentation All staff are taught to become experimentalists - Adapted from Steven J. Spear

12. 12 Role of EMR in Quality & Reliability

13. 13 The Importance of Communication Mr. �Green� Admitted for pleural effusion IR determined that patient appropriate for bedside tap Change in bed teams before thoracentesis No formal hand-off (or time-out) Thoracentesis on wrong side Mr. �Day� Admitted for CT guided FNA of lung mass Transferred to floor where developed SOB and tachypnea Returned to Radiology Survey film Tech marks without noticing patient has been �flipped� for thoracentesis No formal hand-off (or time-out) Chest tube inserted on wrong side

14. 14 What is Efficiency? Technical definition �The relationship between the outputs (goods and services) and the resources input� �Skillfulness in avoiding wasted time and effort� �The elimination of waste or �friction� or other undesirable and undesirable economic features� �Producing growth with little waste� Clinical efficiency Quality outcomes with minimum waste Waste in healthcare Errors Overburdening Uneven flow Motion & transportation Waiting

15. 15 Overburdening and Errors Nurse overburdening Nurse overloading leads to 24% of all sentinel events For each patient over optimum patient-to nurse staffing ratio, the 30 day mortality rate increases by 7%

16. 16 Uneven Flow and Overburdening

17. 17 Waste from Motion

18. 18 2006 VA Inpatient Efficiency Analysis Longitudinal study of 2001-2006 VA inpatient stays Acute medical, surgical, psychiatric, and substance abuse inpatient stays Includes both VA and purchased care Results available by facility and VISN Examines the interrelation of quality and efficiency Emphasis on potentially avoidable complications and adverse events that impact length of stay Compares each VAMC to VA best-practice benchmarks Medicare best-practice benchmarks

19. 19 Methodology � Benchmarking Length of stay (LOS) for each VA inpatient stay compared to a national �well-managed benchmark� using: All Patient Refined Diagnosis Related Groups (APR-DRG) Version 20* grouper to adjust for the severity of illness and resource intensity Other statistically significant variables, including diagnoses, procedures, admission source, discharge disposition, age, gender Above variables account for 80-90 percent of variation in LOS Actual LOS for each VA admission compared to its unique benchmark LOS to identify �potentially avoidable inpatient days� Analysis uses 95% of VA and Medicare inpatient stays National benchmark: well-managed care does not vary geographically APR-DRG V20 and others explain 80-90% of the variation in LOS Hospitals not reimbursed under the Prospective Payment System tend to undercode, while those that are may over-code or upcode. Exhibit D10-1A works through an example DRG to show methodology Analysis uses 95% of VA and Medicare inpatient stays National benchmark: well-managed care does not vary geographically APR-DRG V20 and others explain 80-90% of the variation in LOS Hospitals not reimbursed under the Prospective Payment System tend to undercode, while those that are may over-code or upcode. Exhibit D10-1A works through an example DRG to show methodology

20. 20 Definition of Well-Managed Benchmarks LOS by a well-run delivery system with the appropriate infrastructure, where: Observable evidence-based best practices are used to achieve the lowest utilization possible without adversely affecting quality of care System is not a tightly managed delivery system that compromises quality for efficiency (e.g., denies services)

21. 21 Who Achieves Best Practice Benchmarks? Measure � Number of benchmarks (fewest potentially avoidable inpatient days of care by DRG) More is better 570 APR-DRG VISNs achieve between 4 and 130 benchmarks Top Medicare hospitals achieve between 68 and 143 benchmarks VA best-practice benchmarks VISNs 18, 19, 20, and 23 Medicare best-practice benchmarks Well-known, well-respected hospitals

22. 22 Hospitals Achieving Well-Managed Benchmarks* 570 is the total number of models that Milliman developed for Medicare; one for each severity-adjusted APR-DRG Represents the number of times a facility appears as a most efficient practice VA is affiliated with all medical schools but Sarasota and Mayo Clinic570 is the total number of models that Milliman developed for Medicare; one for each severity-adjusted APR-DRG Represents the number of times a facility appears as a most efficient practice VA is affiliated with all medical schools but Sarasota and Mayo Clinic

23. 23 VA Best Practice* � VISN and Facility Level VISN Med 19, 20 Surg 23 Psy 8 SA 23 Facility Med Salt Lake City, 3,196 Cases Surg Salt Lake City and Sacramento 1,569 and 637 Psych Baltimore, 396 SA Sierra Nevada, 351VISN Med 19, 20 Surg 23 Psy 8 SA 23 Facility Med Salt Lake City, 3,196 Cases Surg Salt Lake City and Sacramento 1,569 and 637 Psych Baltimore, 396 SA Sierra Nevada, 351

24. 24 Potentially Avoidable Inpatient DaysBased on Medicare Best Practice Benchmarks

25. 25 How Do Hospitals Achieve theWell-Managed Benchmarks? Minimize potentially avoidable complications that add to LOS such as: Infections Electrolyte problems Medical mishaps Case management & disease management Flow management Active discharge planning Use evidence-based clinical best practice guidelines Pre- and post-surgery antibiotic use Providing aspirin on admission for heart attack patients Implementing utilization management programs Best observed practices � combination of clinical, quality of care practices and management practicesBest observed practices � combination of clinical, quality of care practices and management practices

26. 26 FIX Collaborative Goal

27. 27 The VA FIX Collaborative Apply systems redesign principles to achieve well-managed benchmarks Reduce avoidable LOS while maintaining or improving quality Reduce inter-facility variability Focus Improve inpatient flow �Physiology, not inefficiency, should determine LOS� Use utilization management to ensure patient in most appropriate bed Reduce medical mishaps and avoidable complications

28. 28 The FIX Collaborative Five regional collaboratives Modeled after the ACA Collaboratives Multiple learning sessions Learn system redesign principles Apply to constraints Performance monitors and measures

29. 29 The FIX Challenge

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31. 31 Discharge Model

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33. 33 Mr. �CPRS Test Patient� Gail Edwards, RN CAC Roudebush VAMC Indianapolis, IN Hypothetical veteran inpatient visit from A-Z demonstrating use of POC and EMRHypothetical veteran inpatient visit from A-Z demonstrating use of POC and EMR

36. Background process VistA/CPRSBackground process VistA/CPRS

37. Healthcare staff/patient interactionHealthcare staff/patient interaction

38. Healthcare staff/patient Continued Assess/Plan/Treat including surgical interventionHealthcare staff/patient Continued Assess/Plan/Treat including surgical intervention

39. Healthcare staff apply background EMR consistentlyHealthcare staff apply background EMR consistently

41. 41 Veteran Arrival ER Veteran arrives at ER Registration begins Triage using ACS Veteran arrives in the ER with wife. Complains of chest pain initiates the Acute Coronary Syndrome protocol.Veteran arrives in the ER with wife. Complains of chest pain initiates the Acute Coronary Syndrome protocol.

42. 42 CPRS Cover Sheet POC Medical History Allergies Warning Notes Advance Directives Current Medications

43. Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

44. 44 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

45. 45 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

46. 46 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

47. 47 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

48. 48 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

49. 49 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

50. 50 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

51. 51 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

52. 52 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

53. 53 Patient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visitsPatient ID Data, Active Problems, Allergies, Active Medications, Recent labs, Vitals, Clinical Reminders, Remote Data, Postings / warnings, Appointments and visits

54. 54 ER RN Triage Note Templated note used by RN to document consistent data for all patients) Includes reminders of protocol content such as chest pain-get EKG STAT And report section for continuity of care.Templated note used by RN to document consistent data for all patients) Includes reminders of protocol content such as chest pain-get EKG STAT And report section for continuity of care.

55. 55 Veteran in ER CPRS documentation initiated EKG obtained EKG transmitted to VistA Imaging

56. 56 EKG Stat Ordered Physician Orders CPRS Order Menu Quick Orders Order sets used to provide best practice and orders standards.Order sets used to provide best practice and orders standards.

57. 57 VistA Imaging Use Vista Imaging to view EKG results by any healthcare staff at the Point of Care.Use Vista Imaging to view EKG results by any healthcare staff at the Point of Care.

58. 58 VistA Web Remote Data Provider checks for previous history VistA Remote Data View Use VistA Remote Data View to see records from other VA sites the patient has visited as well as scanned medical records from non-VAUse VistA Remote Data View to see records from other VA sites the patient has visited as well as scanned medical records from non-VA

59. 59 Vista Web Remote Data VistA Web Remote Data Reveals previous history Echocardiogram at another VA Check for previous echo at all VA sitesCheck for previous echo at all VA sites

60. 60 ACS order set Provider orders ACS Protocol CPRS Order Menu Protocol included on Order Menu Using best practice and Acute Coronary Syndrome protocol at the point of care. Results in consistent care provided.Using best practice and Acute Coronary Syndrome protocol at the point of care. Results in consistent care provided.

61. 61 STEMI Order Set Includes protocol information and action items for order initiation.Includes protocol information and action items for order initiation.

62. 62 Order Screen in CRPSwith all ACS orders Demonstrates how the orders are placed and display on current order screen to be signed by providerDemonstrates how the orders are placed and display on current order screen to be signed by provider

63. 63 ER ACS Admission H&P Progress Note Templates created by CAC using best practice evidence from ACS protocol. Some fields are imported from other sections of the EMR e.g. meds / allergy / labs. Allows for consistent assessment and documentation by the provider.Templates created by CAC using best practice evidence from ACS protocol. Some fields are imported from other sections of the EMR e.g. meds / allergy / labs. Allows for consistent assessment and documentation by the provider.

64. 64 I-Med Consentfor angiogram I Med Consent Nationally used program that interfaces (talks to) CPRS used for electronic consents and education. Provider selects the correct consent.I Med Consent Nationally used program that interfaces (talks to) CPRS used for electronic consents and education. Provider selects the correct consent.

65. 65 I Med Consent Provider reviews the consent has ability to edit text to individualize to veterans needs before signing.Provider reviews the consent has ability to edit text to individualize to veterans needs before signing.

66. 66 I Med Consent Provider obtains patient consent Electronic Signature Pad I Med Consent Creates a note in CPRS and viewable in Vista Imaging.Creates a note in CPRS and viewable in Vista Imaging.

67. 67 I Med Consent Signatures Signature required from provider, patient and witness.Signature required from provider, patient and witness.

68. 68 I Med Consent Education Patient and family education documentation for EMR. Standard page is customizable.Patient and family education documentation for EMR. Standard page is customizable.

69. 69 Education Note in VistA Imaging Finalized note displays in Vista Imaging includes individualized patient notes and wife present.Finalized note displays in Vista Imaging includes individualized patient notes and wife present.

70. 70 I Med Consent Education Education available for the Cardiac Cath from IMed Consent gallery.Education available for the Cardiac Cath from IMed Consent gallery.

71. 71 CPRS Procedure Consent CPRS Note showing procedure consent showing IMed Consent completed.CPRS Note showing procedure consent showing IMed Consent completed.

72. 72 VistA Imaging  Viewing the Consent Vista Imaging display the completed IMed Consent for the procedure.Vista Imaging display the completed IMed Consent for the procedure.

73. 73 Education Note in CPRS CPRS Progress Note CPRS Progress note refers to VistA Imaging for the complete educational note. The blue photo icon indicates there are images associated with this note.CPRS Progress note refers to VistA Imaging for the complete educational note. The blue photo icon indicates there are images associated with this note.

74. 74 Medication Administration BCMA Medication Bar Code Scanner Confirms Ordersfrom CPRS Mr CPRS has been moved to the MICU awaiting cardiac cath. The EMR is available at the point of care.Mr CPRS has been moved to the MICU awaiting cardiac cath. The EMR is available at the point of care.

75. 75 BCMA Medication Bar Code Medication Administration Scan patient wrist band Scan medication Nurse verifies the medication due in BCMA.Nurse verifies the medication due in BCMA.

76. 76 Veteran needs CABG Provider confirms need for CABG The veteran Mr. CPRS needs surgical intervention!The veteran Mr. CPRS needs surgical intervention!

77. 77 Cardiology Cath Report CPRS Progress Notes Report in CPRS Mr CPRS has completed the CABG. Cath report available in CPRS.Mr CPRS has completed the CABG. Cath report available in CPRS.

78. 78 Cardiac Post Op Order Screen CPRS Order Set Most frequently used Cardiac Post Op Use of Best Practice for post op orders used to create an order menu for cardiac post op.Use of Best Practice for post op orders used to create an order menu for cardiac post op.

79. 79 Anesthesia Notes Anesthesia Post Op and Transfer Notes (handoff) to provide consistent records immediately for transfer from Anesthesia to Critical Care. Developed by Chief of Anesthesia. Include antibiotic to prevent duplicate dosing.Anesthesia Post Op and Transfer Notes (handoff) to provide consistent records immediately for transfer from Anesthesia to Critical Care. Developed by Chief of Anesthesia. Include antibiotic to prevent duplicate dosing.

80. 80 BCMA �What happens if you build it and they do not come?� BCMA introduced to reduce medication errors in 1999 Bypassing / workarounds persist 94 incidents since October 2002 10 of 13 aggregate RCA related to BCMA Bar Code Medication AdministrationBar Code Medication Administration

81. 81 Previous Improvement Activities Wristband printers replaced Increased number of laptops CAC-BCMA Coordinator created and filled NSL locks/Central lines/flushes Hemo-dynamic flushes Multi routes of same med BOG Meeting IVF/IVSS documentation Missed Medication and PRN Reports (auto-print) LR/NS Bolus stocked on floors No more D5W on floors Removed barcodes from patient labels I-Carts

82. 82 BCMA Rapid Improvement Team Rapid Improvement Team consisting of multiple disciplines from the VA and RCHE. Staff nurses, BCMA Coordinator, Pt. Safety Officer, industrial engineers met over one week.Rapid Improvement Team consisting of multiple disciplines from the VA and RCHE. Staff nurses, BCMA Coordinator, Pt. Safety Officer, industrial engineers met over one week.

83. 83 Pass Meds � 4 patients Black before RPIW Red after rapid cycle changesBlack before RPIW Red after rapid cycle changes

84. 84 Initial Observation Summary Averages (4 patients) Steps per patient: 181 steps Attempts: 3.3 Total time per patient: 18 mins Supply time per patient: 9 mins Med administration time: 9 mins

85. 85 Affinity Diagram / T-Chart Results Multiple log-ins No tool for planning med pass Isolation boxes not stocked Patient not available Rehab Supplies for med pass not available at POC Water IV meds Supplies PRN meds Interruptions Tom PryorTom Pryor

86. 86 Current State

87. 87 Impact of POC Improvements Rapid Cycle changes-RCC Steps from 181 to 33 total time from 18 to 3 and dispense from 9 to 3Rapid Cycle changes-RCC Steps from 181 to 33 total time from 18 to 3 and dispense from 9 to 3

88. 88 Cart Enhancements Fourth drawer large to hold IV approved and on orderFourth drawer large to hold IV approved and on order

89. 89 Veteran Discharge Safe Care Provided Utilizing EMR Veteran goes home

91. Emerging EMR Tools Peter A. Woodbridge, MD, MBA ACOS for Quality & Clinical Informatics Roudebush VAMC Indianapolis, IN

92. 92 ED OvercrowdingManaging Constraint

93. 93

94. 94 ED Bed Board

95. 95 Inpatient Bed Board

96. Patient Status

97. 97 Beds Needing Cleaning

98. 98 Patient�s Waiting for Bed

99. 99 Role of EMR in Quality & Reliability

100. 100 Handoff Tool

101. 101 Handoff Tool

102. 102 �To err is human� A (The?) purpose of the EHR is to reduce errors by improving communication, eliminating ambiguity, and increasing reliability (and efficiency)

103. 103 QUESTIONS?