Systemwide collaborative targets capacity woes
Long journey seeks the door-to-doc Holy Grail’
An ambitious collaborative involving an entire hospital system plus experts from a neighboring engineering school are systematically analyzing the causes of capacity constraints and developing strategies to address them at one hospital. To date, they have already achieved a nearly 33% improvement in the number of ED admits in under 90 minutes — from 32% to 42.3%. Ultimately, they hope to develop a toolkit that will ensure a typical door-to-doc time of fewer than 20 minutes.
The partnership involves Banner Health, Arizona in Phoenix, which includes 20 hospitals in the western United States, and Jeffery K. Cochran, PhD, professor in the Department of Industrial Engineering, at the Ira A. Fulton School of Engineering at Arizona State University in Tempe.
Banner Health has involved engineering in its health care environment for more than 20 years and has 12 management engineers in its system, says Twila L. Burdick, MBA, FHIMSS, vice president of organizational performance. "That’s how we got acquainted with Jeffrey," she says. "He was interested in more advanced applications and asked if there was an opportunity for us to work together."
At about the same time, Banner Mesa (AZ) Medical Center had participated in a 15-month effort in the Boston-based Institute for Healthcare Improvement’s "Patient Flow Collaborative." That collaborative ultimately became the basis for the new Banner Health model.
Engineering is a natural for the ED environment, Burdick asserts. You have to make a lot of decisions in a hurry, she explains. "Often they are made through a sort of gut feeling," Burdick says. "The potential for improvement lies is the fact that the data can tell you more than your gut can tell you."
The research is focusing, in part, on aspects of systems flow and "queuing" theory: looking at how and why lines form, how they grow and diminish, and how people perceive and react to them. That process involves creating computer models of EDs to study their operations in relation to other hospital departments, and educating managers about how systems-flow principles can be taught to hospital staff.
Through the collaborative, models were developed that illustrated not only the different forces that impact capacity problems, but the interrelationship between departments within the hospital and between hospitals within a system. "We often modeled the ED and the interaction between the ED and the hospital," says Burdick.
Chris Modena, MBA, BSN, the ED director of Good Samaritan Regional Medical Center in Phoenix, says, "One of the most interesting things that has evolved along with this project is what we’ve learned from Jeff about what statistics are important to us and how predictive they can be."
For example, she says, "We have found Jeff’s numbers predicting the number of rooms we need for the different services and the number of required providers based on historical data to be the most helpful in planning the future of the emergency departments." Although one would think the ED is unpredictable because the visits are unscheduled, she asserts that Cochrane’s research "Proved there are patterns of times of patient entry, patterns of acuity, and patterns of provider services."
The collaborative model in action
The structure of the collaborative model works like this: It begins with a kick-off conference, attended by the local interdisciplinary teams from each facility. This is followed by Action Period 1, during which different teams make improvements, report on their progress and share their experience via conference calls. During this period, systems engineering tools can be applied to specific issues.
Next is a Learning Session, which included a lecture on "the science of throughput" by Cochran. Ultimately, this process will include Action Period 2, another learning session, and finally the institutionalization of improvements. "We are right in the middle of the process," he reports.
What concrete accomplishments have been seen to date? "We have nearly completed a pretty outstanding ED scorecard for all our EDs, related to the kinds of metrics we want to be measuring," reports Burdick. "It lines up all the EDs in terms of volume, holding statistics, lost revenue, time it takes to be seen, and so forth."
Another interesting tool that has been developed is a David Letterman-style list of the "Top 10 Ways to Make Throughput Worse." (See box.) To make the concepts easier to apply, the list was later rewritten into the "Top 10 Ways to Improve Throughput."
Design team defined new model
In their collaborative work, the system pulled together a design team from across the system that included Modena. It also included the ED redesign group, a nurses’ group, and a physicians’ group.
"They spent many hours defining what this new model should look like," Burdick says. "Only after that did we go forward with and put some measures behind it."
As one component of the collaborative, the team has been awarded a $600,000 grant from the Agency for Healthcare Quality and Research that will fund the development of D2D, a toolkit designed to speed flow and improve patient safety.
"The toolkit is the deliverable for the grant, which ends June 2007," says Cochran.
"We have a working toolkit on our intranet — a living’ toolkit, if you will," says Burdick. "As a facility finds an item that is particularly useful, we borrow that and put it in the toolkit."
The effort is not just about saving time, but about patient safety as well, Cochran says. "[ED physicians] respond to the recommendations not so much to improve the productivity of the ED, but because they see access as a patient safety issue," he explains. "That really resonates with them." Also, door-to-doc time in the ED is a measured and financially rewarded metric, he says.
Sources
For more information on collaborating to improve patient flow, contact:
- Twila L. Burdick, MBA, FHIMSS, Vice President, Organizational Performance, Banner Health Arizona, 1441 N. 12th St., Phoenix, AZ 85006. Phone: (602) 495-4518.
- Jeffery K. Cochran, PhD, Professor, Department of Industrial Engineering, Ira A. Fulton School of Engineering, Arizona State University, Tempe, AZ 85287-5906. Phone: (480) 965-2758. Fax: (480) 965-8692. E-mail: [email protected].
- Chris Modena, MBA, BSN, ED Director, Emergency Department, Good Samaritan Regional Medical Center, 1300 N. 12th St., Phoenix, AZ 85006. Phone: (602) 239-2106. E-mail: [email protected].
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