1. Patient Safety Summit Throughput- Led Initiatives with EPIC Source Data January 8, 2014 Judy Shepard, RN, MN Director, Quality/ Bed Management Raymond Smith, MBA Director, Clinical Decision Support 1

2. Conflict of Interest Disclosure Raymond Smith, MBA Judy Shepard, RN, MN Has no real or apparent conflicts of interest to report. 2

3. Learning Objectives Learn how Grady used the EPIC system to improve patient throughput and communication to allow inter-professional collaboration towards a strategic goal- improving patient care. Hear how analysis exercises through LEAN/ Six Sigma can be used to convey and reinforce key concepts in quality improvement. Assess the theory behind sampling strategies and the necessity of applying appropriate statistical techniques to analyze EPIC data and make valid inferences. Learn tips for improving EMR adoption at the staff level. Review methods for providing process improvement initiatives to reduce turnaround times and optimize patient throughput efficiency. 3

4. Grady Health System, Atlanta Georgia Level 1 Trauma Center in the center of the city of Atlanta Premier Regional Academic Medical center with two schools of medicine (Emory and Morehouse) Operating at capacity with need to grow 953 licensed beds; 26,000 admissions 22 Hospital based Specialty services and 6 NHC, nearly 620,000 patient visits Including 300,000 Emergency visits 4800 employees; 1000 physicians 4

5. Our Challenge Decrease the average LOS in the ED from median of 7.0 hours in 2012 to 6.0 hours in 2013 Decrease door to provider time in the ED from 2.4 hours in 2012 to 1.75 hours in 2013 Decrease LWBS rate in the ED from 30% in 2012 to 15% in 2013 Improve efficiency in processing time from decision to admit in ED to patient placement in bed. 3 hours in 2012. 5

6. Current ECC 6

7. "MD Order To Patient Placement" Timeline July 2012 to October 2013 7

8. Reminders Policies, Procedures, & Processes Safety Culture External Environment AcuityBehavior Multi- disciplinary Teams Systematic PI models Clinical Leadership Sufficient Staff Knowledge Audits & Feedback QI Perspective 8

9. Why does Workflow Matter? Understanding of “How We Care for Patients” –“Physiology” as well as “Pathophysiology” of a health care delivery system Necessary to Improve the Quality of Patient Care –Fundamental to achieving desired Quality Outcomes (IOM): Safe, Timely, Effective, Efficient, Patient-centered –“Lack of knowledge... that is the problem… if you can't describe what you are doing (as a process), you don't know what you're doing.” –W. Edwards Deming Impacts Facility, Process, and IT Design, as well as Training, Policy, and Culture: –Must understand in order to optimally manage and improve –Critical to avoiding Unintended Adverse Consequences –IT Systems must integrate into and facilitate optimal workflow Stead IOM/NAE (2009), Karsh AHRQ (2009) Checklist Manifesto –Volume and complexity of knowledge has exceeded our ability to deliver quality consistently without a simple tool- the checklist 9

10. Admissions Intake Inpatient CareDisposition Global View of Patient Throughput Information Systems ECIN Invision Emergency Department Initiation of rapid care protocols Streamlined triage processes Bed-side registration Effective Patient Throughput MD Coverage Timely discharge order Coordination with Case Manager/ Social Worker Case Mgmt Prioritize discharges Coordinate with Nursing/Physicians Long stay patient placement Family communication ICU/Step-down/ Telemetry Facilitation of patient transfers Placement of Long Stay patients Nursing Units Coordinate with Case Mgmt Point person for facilitation of flow Initiation of bed cleaning Diagnostic Testing Timely TAT Scheduled inpatient testing Guest Services Coordination with Nursing and ED Environmental Services Coordination with Bed Mgmt and Nursing to match demand Global View of Patient Throughput Direct Admissions from Clinics Screening for appropriateness Avoid direct admissions going to the ED External Facility Transfers Screening for appropriateness Requires financial clearance Perioperative Services Improved OR prep for day of surgery Improved start of day activities Improved start and TAT Develop case scheduling process Bed Management Anticipatory planning for beds Coordination with Case Manager for discharges Global view of all beds Physician champion to facilitate timely discharge Day of Discharge Communication with family Nursing/Case Manager/Social Worker support at the discharge Notification of dirty bed Timely bed turnaround 2 10 Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

11. Team CharterBaseline Data Root Cause (s) Confirmed with Data Cost- Benefit Analysis Implementation Plan Standard Operating Procedure Value Stream Mapping Kaizen Events (Rapid Cycle Activities) Results SIPOC Detailed Workflow Voice of the Customer Pilot Results Implemented Process Monitoring Plan Initiate, scope, and plan the project Understand the current process Determine and verify root causes of problems Develop and test improved process Implement and monitor improved process Provide support for ongoing management of process DefineMeasureAnalyzeImproveImplementControl Deliverables Six Sigma DMAIC Methodology and CDS Tools (fact based decision making) 11

12. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 12

13. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 13

14. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 20,649 cases reviewed 14

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16. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 16

17. Focus of Lean: Elimination of Waste 17

18. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 18

19. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 19

20. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 20

21. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia 21

22. Throughput Patient Flow Initiatives for PI Team assessment pull process- ICU admissions Increase utilization of the Discharge Lounge Preliminary Discharges the day before Capacity plan to admit high volume/ peak time admissions Enhanced communication between Attending/Residents Increase mid-level (s) at peak times of ED volumes Step Down Criteria for Flow/Placement Optimization 22

23. Quality/ Performance Improvement 2013 Recommendations PillarRecommendation(s) People ↑ volumes of medical screenings in ECC waiting room by Mid-level providers/ Nurse practitioners Process Blast page notification to all MD’s for priority to triage discharge patients out of critically staged beds during times of ED saturation Quality Standardized use of evidence based order sets/ nursing care plans for high volume diagnosis level 3’s in ECC on most common chief complaints Growth Bed availability must be operationally addressed to meet expanded need for step down/ ICUs. 23

24. Bed Management Model 9 The dedicated RN Bed Czar has an overview of all beds at all times and addresses any challenges in bed placement, plans proactively for the next day and works with Nursing, PACU, Case Management, ED, Admissions, Guest Services, Housekeeping, Physicians, etc., to appropriately place patients. Source of Admission Admissions evaluates bed board and places patient in appropriate bed. Admissions notifies Charge RN of admission. Charge Nurse calls back within 10 minutes with final clean bed assignment on the unit. PACU, Cath Lab, other procedure areas RN Bed Czar Admissions CM Admissions CM performs clinical review for appropriateness of admission ED Direct admissions from clinics and transfers from other hospitals Patient Access Financial screening performed by PAR Charge RN or Unit Designee Admissions PACU, Cath Lab, other procedure areas ED Direct admissions from clinics and transfers from other hospitals Each area notifies Admissions of bed need via system ~ 1 hr. prior to bed needed Physician/designee calls admissions CM with patient clinical information and discusses plan of care ED CM performs clinical review for appropriateness of admission. Unit Secretary notifies Admissions of bed need. Report automated/faxed. Receipt of report verified and questions answered. Patient transferred w/i 30 min Pages charge RN/designee w/ bed assignment. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

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26. Insights and Lessons Learned 1.Must include Direct Observation, Record 2.Don’t forget the Clinical dimension 3.Repurpose Data currently in environment 4.Consider Multiple Methods 5.Focus on time or resource consuming tasks 6.Don’t miss Rare or Critical events, interruptions, workarounds, or delays 7.Simulations force detailed descriptions of work and are good for communicating with subjects and testing interventions or scenarios 8.Consider all “Systems”, their respective “Lifecycle” state, and Contextual Factors 9.Need for a Systematic, Interdisciplinary Approach to study workflow 10.Engage Leadership and Staff 26

27. Thank You Questions??? 27