Bay Pines Carey Award Journey

1. Bay Pines Carey Award Journey Lithium Lin, MD, Chief of Medicine Karen McGoff-Yost, LCSW, Program Analyst, Surgery Service Debi Bailey, LCSW, MPH, HSS, Geriatrics and Extended Care Bay Pines VA Healthcare System Carey Award Symposium October 2010

2. Waits and Delays Bay Pines on Divert >50% in winter months Quality of Care not optimal A Problem in 2004

3. What are the symptoms when you don’t have Inpatient/Hospital Flow? • Hospital Closure/Diversion • Patients diverted to another Hospital • Higher Fee Cost • Overcrowded ER • Patients sitting in the ER/hallways for hours • Delayed Procedures • Cancelled Surgeries • Gridlock • Angry Patients • Stressed Staff • Poor Outcomes • Patient Safety Affected • Waste of Resources 3

4. What are some ways to Improve Flow or do Inpatient System Redesign? Build more beds & hire more staff (expensive) Analyze, improve processes/communication & target resources/incentives (efficient) 4

5. A Closer Look at the Problem in 2004 Bay Pines Medicine ALOS = 6+ days InterQual on BDOC only about 60% Everybody had an anecdote as to why pt did not meet criteria Everybody was pointing their finger at someone else

6. Bad Delays vs Good Delays Waiting a few days for inpatient to recover from pneumonia before surgery is a good delay Waiting a few days for OR availability because of poor planning, poor communication, etc is a bad delay. Work to reduce bad delays 6

7. Concept of Avoidable Days Bed Day of Care that could have been avoided if the system operated optimally Often self-evident in CPRS charting E.g. “Await Surgery input”, “Await CT results”, …

8. Drill Downs The need to drill down to meaningful and actionable data The need for UR Nurses and Hospital Managers to provide constant feedback to each other

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10. Radiology Avoidable DaysPart I • By 2005 at Bay Pines, we realized Radiology was #1 inpatient delay. • And CT was #1 delay within Radiology • Improved TAT with expanded hours • Hired additional staff 10

11. Avoidable Days due to CT Scans

12. Avoidable Days due to CT Scans: 2005 vs. 2008

13. Radiology Avoidable DaysPart II • We then redesigned inpatient CT ordering to scanning process • We later also implemented Off Ward Policy which had other collateral benefits • Essentially now we have CT on Demand 13

14. Old Flow Chart Several Hours may pass Pt. may not be in room If pt. not available, CT cancels test w/o informing anyone

15. New Flow Chart

16. Off Ward Policy • Implemented in 2007 • Updated and strengthened in 2009 • Reduced off ward patient injuries • Improved monitoring, infection control • Side benefit of improved flow 16

18. Nuclear Medicine Avoidable Days Part I The next most important delay was Nuke Med Avoided 2-day tests in favor of 1-day tests Expanded Nuclear Medicine Services for OP on Saturday, which aided IP; particularly helpful on 3-day weekends 18

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20. Avoidable Days due to Stress Tests: 2005 vs. 2008

21. Nuclear Medicine Avoidable Days Part II Variability in inpatient nuclear stress test demand Working on predicting demand based on season, weather, DOW Working on alternatives such as DSE 21

22. Cardiology Avoidable Days Part I Paid OT for Echo Techs to come in on Saturdays Worked with Cardiologists to read Echos on Saturdays Now working on after-hours Echo 22

23. Cardiology Avoidable Days 23

24. Avoidable Days due to ECHOs: 2005 vs. 2008

25. Cardiology Avoidable Days Part II Improved throughput through Cath Lab Mostly Interventionalist dependent Improved EMS turnover of the lab also helped Now building 2nd Cath Lab 25

26. Cardiology Avoidable Days Cont’d 26

27. Avoidable Days due to Cardiac Caths: 2005 vs. 2008

28. Radiology Avoidable Days Most of the improvements in other areas of Radiology came from service agreements & building capacity For example for PET scans, service agreement outlined who can order what test. 28

29. Radiology Avoidable Days Cont’d 29

30. Avoidable Days due to MRIs: 2005 vs. 2008

31. Radiology Avoidable Days Cont’d 31

32. Coumadin/Heparin Regulation Avoidable Days • Unexpected top delay in 2008 • Found Hospitalists tended to keep patient longer than necessary • Moved Coumadin regulation responsibility from Hospitalist to Pharmacist 32

33. Coumadin/Heparin Regulation Avoidable Days • Automatic Pharmacist consult generated when Coumadin is ordered on a patient • Coincidental with Joint Commission Patient Safety Goals 33

34. Coumadin Avoidable Days 34

35. GI Avoidable Days • Cost-benefit analysis did not favor routine GI procedures on weekends • But weekend GI pts did not get their procedure til Tuesday • Improved weekend communication btw Hospitalist & GI so pt got procedure 1st thing Monday AM 35

36. Avoidable Days due to Colonoscopy/EGD: 2005 vs. 2008

37. Results: Decreased LOS Medicine Service 37

38. Further Interventions Resulting in Reduced Avoidable Days (Medicine) 38

39. Contributors to ALOS reduction • Hospitalists unwedded from wards • Hospitalists wedded to teams • Improved Inpatient Continuity of Care • Increased Hospitalist & Patient Satisfaction • Improved Flow 39

40. Medicine Admissions • Linear increase in admissions from FY 2002 to FY 2009

41. Increased acuity levels in patient population based on Continued Stay Review (UR) data 41

42. FY 2009-2010 OMELOS data: Lower is Better 42

43. Diversion Rates • Improvement of Hospital Diversion/Closure rates from FY 2006 to FY 2010. 43

44. Incentives • Admission Meeting Criteria and ED Flow Measures are part of ER Physicians’ Performance Pay Goals • Also part of provider-specific data for recredentialing • Daily feedback given by UR Nurses 44

45. Incentives • Hospitalist Performance Pay Criteria includes key factors as well • Continued Stay Meeting Criteria • ALOS • Readmission within 30 days • ED Flow Measures • Combined rank of ALOS, D/c before noon, Readmission rates • Avoidable Days part of Medical Specialists’ Performance Pay • i.e. Avoidable Days due to Echos for Cardiologists 45

46. Flow Initiatives at BPVAHCS • Home Page Icon • Bed Czar • ED Bed Board • IP Bed Board • Expansion of ED • Expansion of telecapacity by converting Gen Med beds to tele-capable 46

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48. Home Page Icon Place on Facility Home Page signals its importance to staff Easy to tell at a glance whether the facility is open (green), divert (yellow) or closed (red) Most up-to-date status No more confusion

49. Bed Czar Position officially called Bed Flow Coordinator Works much like Air Traffic Controller Also Manager of Bed Management System; Runs daily VISN Bed Huddle Call

50. Emergency Department Information System ED Bed Board Can track reasons for ED Stay >6H Bed Czar can anticipate admission and get beds ready Managers can tell at a glance whether there is gridlock from number of patients with significant ED LOS