Presented by, Matthew Rusk, D.O. Advisor: Khalid Qazi, M.D. Objectives Introduce a concept that augments the admission process by improving: Admission wait times Patient satisfaction Quality Cost Effective Care Explain how change was implemented Discuss results Compare results to current literature Introduction—Lean Flow Business concept that is well known and implemented daily by successful businesses Often ignored in the healthcare industry Gaining recognition in healthcare Can make healthcare efficient and improve quality Introduction ED overcrowding is associated with worse quality of care and service delivery quality (1); Recent studies have shown clearly that wait time directly affects patient satisfaction (1-9); Time to evaluation can also influence whether or not a patient is seen at all (1, 2, 10). Hypothesis Utilizing lean flow will improve the admission process at Sisters of Charity Hospital by: Decreasing the total admission process time Improving patient satisfaction Enhancing quality Improving Cost Effective Care Methodology Implementation of Lean Flow X32 Healthcare ‘Rapid Improvement 3-day Program’ ○ CHS Staff; ○ Four Residents; ○ Lean Flow Education; ○ ‘Front end’ Improvements; ○ Little focus on admission process Methodology Applied concepts to improve admission process Key Changes: ○ Admission Orders within 30 min; ○ ED Holding Orders in certain situations; ○ Earlier Bed Search; ○ Easier access to order sets, charts and labels Methodology Outcome measures Time Patient Satisfaction Quality and Safety Cost Effective Care Methodology Pre-intervention March 1 through October 31, 2008-2011 Intervention November 2011 – February 2012 Post-intervention March 1 through October 31, 2012 Methodology-Time Intervals Arrival ED Provider TAPI Admit Order Departure Arrival to Departure (total admission time) Arrival to ED Provider ED Provider to Time Admitting Physician Informed of admission (TAPI) TAPI to Admit Order Admit Order to Departure Methodology-Patient Satisfaction Questions: Got help as soon as wanted Quiet around room at night Treated with courtesy and respect by doctors Treated with courtesy and respect by nurses Rate Hospital Would recommend hospital to family Answers 9 or 10 out of 10 defined as perfect score 8 or below defined as non-perfect (negative response) Methodology-Quality Indicators Inpatient Specific ED Specific Fall Rate Left Without Being Seen (LWBS) Core Measure Compliance AMI, HF, PN, SCIP ED Mortality RRT calls Inpatient Mortality Methodology—Cost Effective Care Average LOS ED Volume Total Admissions Results—Time Variables Summarized using means and standard deviations. An independent two-sample t-test using assumption of equal variances was used to test for differences in means. A multiple regression model was used to test for differences adjusted for baseline variables (age, gender, race, Arr Method, and Bed Type). Time Interval Comparison Time (minutes) Time (minutes) (Decrease of 78.8 minutes [417.8 – 339 = 78.8]) Statistically Significant, P-value <.0001 Time (minutes) (Decrease of 35 minutes [168.5 – 133.5 = 35]) Statistically Significant, P-value <.0001 Time (minutes) (Decrease of 36.2 minutes [61.9 – 25.7 = 36.2]) Statistically Significant, P-value 0.0015 Summary of Time Variables Arrival to Departure (Total Admission Time) Decrease of 78.8 minutes 19% reduction in total admission time Most of our overall improvement during TAPI to Dep TAPI to Departure Decrease of 71.2 minutes 31% reduction of this TAPI to Admit Order Decrease of 36.2 minutes 58.5% reduction of this interval Admit Order to Departure Decrease of 35 minutes 21% reduction of this interval Results—Patient Satisfaction Summarized using frequencies and percentages. A Pearson chi-square test was used to compare the proportion of satisfaction between pre and post. Odds ratio and corresponding 95% confidence interval was calculated. Hospital Rating Chi-square test: Odds Ratio: Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF 1 Value 1.7981 Value 16.7623 Prob <.0001 95% Confidence Limits 1.3561 2.3843 Would Recommend Hospital To Family Chi-square test: Odds Ratio: Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF 1 Value 1.6931 Value 12.5009 Prob 0.0004 95% Confidence Limits 1.2629 2.2698 Treated With Courtesy and Respect By Doctors Chi-square test: Odds Ratio: Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF 1 Value 1.7113 Value 10.0276 Prob 0.0015 95% Confidence Limits 1.2246 2.3914 Treated With Courtesy and Respect By Nurses Chi-square test: Odds Ratio: Statistic Chi-Square Type of Study Case-Control (Odds Ratio) DF 1 Value 1.7703 Value 11.0264 Prob 0.0009 95% Confidence Limits 1.2606 2.4861 Patient Satisfaction Results All questions showed significant improvement post-intervention. Hospital Rating Scores improved to 70.2% (from 56.74%) Recommend to Family Scores improved to 74.94% (from 63.85%) Results—Quality Summarized using means and standard deviations An independent two-sample t-test using assumption of equal variances was used to test for differences in means. Improved Inpatient Fall Rate Falls significantly decreased (p-value < 0.0001) Improved ED Left Without Being Seen (LWBS) 38% reduction in LWBS p-value is < 0.0001 Improved Core Measure Compliance Percentage of Perfect Care Pre (%) Post (%) P-value AMI 91.41 100.00 0.0956 HF 84.35 100.00 <0.0001 PN 84.99 94.44 0.0293 SCIP 84.98 92.61 0.0006 Decreased Number of Rapid Response Team Calls p-value = < 0.001 Statistically Significant Mortality Inpatient p-value = 0.9053 No significant difference ED p-value = 0.6264 No significant difference Quality Summary Inpatient Specific ED Specific Improved Inpatient Fall Rate Improved Left Without Being Seen (LWBS) Improved Core Measure Compliance AMI, HF, PN, SCIP No change in ED Mortality Decreased RRT calls No change in Inpatient Mortality Results—Cost Effective Care Summarized using means and standard deviations An independent two-sample t-test using assumption of equal variances was used to test for differences in means. Improved Length of Stay Average LOS decreased from 4.68 days to 4.36 days (p-value < 0.0018) Increased ED Volume and Admissions ED Volume increased 13.5%: Pre Volume avg = 23,624 Post Volume = 26,799 (March-Oct) Admissions Increased 3.5%: Pre Admission Avg = 4,002 Post Admission = 4,141 (March-Oct) Cost Effective Care Summary Improved Average Length of Stay Increased ED Volume Increased Admissions Discussion Yale-New Haven Hospital utilized lean and reduced the time from decision to admit [TAPI] to transfer to floor [departure] by 33% (11) Anecdotal recount We had a 31% reduction of this time frame. Lack of studies focus on admitted patients. Lack of focus on admission times, affect of overall hospital rating after admission Limited investigation on inpatient quality. Conclusion Our study fills void ○ focus on how lean affects the admission process and subsequent hospital stay. Implementing Lean Flow at Sisters Hospital Significantly Improved Admission Times Significantly Improved Patient Satisfaction Significantly Enhanced Quality Facilitated Cost Effective Care Conclusion Further improvements are possible Focus on specific time intervals Re-evaluate processes Lean Flow works and is an essential tool implement in healthcare. Acknowledgements Marylin Boehler, RN, Director of ED and Critical Care Julie Morgante, Quality Analyst, Quality & Patient Safety Department Terry Mashtare, PhD, UB Statistics Department Jingjing Yin, UB Statistics Department Entire Sisters Medical Records Department Abid Hussain, MBBS, IM Resident Sameer Waheed, MBBS, IM Resident Mohammad Tantray, MBBS, IM Resident Nancy Roder RN, BSN, Application Analyst, CHS Information Technology X32 Healthcare—Lean Consulting Firm Chuck Noon, PhD Brian Livingston, MD, MBA Jody Crane, MD, MBA Kim Adams, RN References 1. Eitel DR, et al. 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