Background
Improving the healthcare experience often goes hand in hand with improving the quality of care. Healthcare providers that prioritise patient-centred care are more likely to have effective communication, coordinated care, and comprehensive support services. These factors can enhance the accuracy of diagnoses, increase adherence to treatment plans, and reduce medical errors.
By improving the healthcare experience, these healthcare providers can enhance patient satisfaction, improve the quality of care, increase patient engagement, boost their reputation, achieve cost savings, and fulfil their ethical responsibilities.
Our client is a healthcare provider founded in the late 1800s. Since then, they have grown to serve a 17-county region across three states. With almost 3000 employees, they are federally designated as a Regional Trauma Centre. They employ over 200 physicians and mid-level practitioners and admit over 10,000 patients annually.
Analysis
The client was just a year away from moving into newly constructed, state-of-the-art operating rooms (OR). They knew that their systems and processes could be improved — and understood that they would be moving problems and bad habits into their new space if they didn’t do it now.
Additionally, their emergency department (ED) was also nearing capacity given their growing average length of stay (ALOS). ED management was in favour of including costly additions to accommodate more patients.
From our analysis, we discovered a few areas of concern:
- While ‘block scheduling’ (generally a hold on several hours or ORs by a department) is “owned” by the client, they did little to manage its efficacy.
- Their current ORs were scheduled for use (‘Schedule Fill’) for only 40% of the available time.
- Schedule Fill is about 18% when design capacity is considered
- Lack of active supervision of the professional staff.
- ED room turnover time is lengthening cycle times and causing capacity issues.
- Lack of an effective system in ED to process incoming patients.
- Available information is weak and not aligned with the pace of work.
- Leadership unable to use data to drive improvement.
Based on the outcome of our analysis, it was agreed that a need for relevant, timely data and KPIs were needed to drive the change process. It was also agreed that changes in ED ALOS and OR utilisation would need to be made.
Project Approach
We began the transformation project by setting up two Management Action Teams (MATs) — one for the ED ALOS reduction, and one for the OR utilisation capacity improvement. Both would report directly to the executive steering committee comprised of the CEO, CFO, CNO, VP Support Services, and CMO.
The 32-week project began by drilling down into the key processes and behaviours that would need to be altered. The ED ALOS team focused on reducing the time before a patient saw a doctor and the time deciding if a patient should be admitted to the main hospital as an in-patient. The OR team primarily focused on pre-admission testing, incomplete charts, first case start delays, schedule fill, turnover time, and surgeon block/OR utilisation.
Project Implementation
Changes by the ED ALOS team produced an ALOS decrease from 177 to below 155 minutes. This was accomplished by including a Charge Nurse rounding tool, with daily reporting on any patients with a length of stay (LoS) over 2 hours, and by changing to a care team model instead of individual MDs and nurses.
Our trials showed a significant decrease in ALOS was possible by stationing an MD in the Triage department once the ‘decision to admit’ time was reduced. To accomplish this, a LoS MAT was created to improve the ability of moving patients though the system in a more controlled manner.
In the OR, changes began with removing and adjusting blocks from groups who habitually underutilised them. We then focused on improving ‘first case on time starts’ and reducing room turnover times. As the efficiencies came through and additional OR volume did not materialize, we began to reduce on-call OR staff to match the number of procedures.
“We tried several years ago to take back surgeon blocks. What is different this time is that it is data-driven and has included the surgeons in the process.”
CNO
Many changes in routine behaviour and culture took hold, including a focus on completion of patient documentation and charts before surgery, anaesthesia taking an active role in the next day’s OR scheduling, and a twice-daily hospital-wide ‘bed huddle’ led by the ED. This huddle afforded all participants the opportunity to discuss ALOS and patient flow throughout the entire hospital.
Key Results
180%
Removed surgical blocks of current OR peak time
12%
Reduction in average length of stay (ALOS)
The real benefit of the project is that the client has created a better work environment for their staff, a better place to be treated for their patients, and a better place to attract additional physicians, practices and patients.
The OR now has 22% open capacity, and the ED 12% has more time available for additional patients. They are also able to track, report, and respond to changes that negatively affect performance on a real-time basis.
Ultimately. the client has created a culture of continuous improvement to match the rate at which healthcare in the United States is currently changing.
