Clinical Safety & Effectiveness Cohort 16|Team 4

DECREASE PATIENT LENGTH OF STAY (LOS) THROUGH USE OF “ANTICIPATE DISCHARGE”

ORDERS ON 5ACU

DATE

The Team • CS&E Participant

– Kanapa Kornsawad, MD Clinical Professor/Hospitalist, Medicine Service

– Ronald Estrella, RN Executive Director, Medicine Service Line

– Mario Legarde III, RN Clinical Nursing Director, Medicine Service Line

– John Rees, RN Patient Care Coordinator, 5ACU

– Sadaf Rafique, MS Manager, Health Analytics

• Ad Hoc Team Members

– Sebastian Padron Director, Ambulatory Care Coordination

– Dorothy Krumbholz Care Coordination Director, Inpatient

– Medical and Nursing team 5ACU

• Sponsor

– Luci Leykum, MD, MBA Division Chief, Hospital Medicine

– James Barker, MD , CPE VP/Medical Director, University Hospital

• Facilitator

– Edna Cruz, RN Improvement Consultant, Clinical Safety & Effectiveness

The aim of this project is to decrease patient length of stay (LOS) through use of “anticipate discharge” orders on 5ACU from 6.9 days to 6.4 days by May 17th.

The process begins with admission to UH

and ends when patient is discharge home or

to a facility.

It is important to reduce patient length of stay to increase capacity for the Health System, resulting in bed availability, reduction in wait times, and improved patient experience.

Aim Statement

Dec-14 Jan-15 Mar-15 Apr-15 Jun-15

Team created

Aim statement created

Background data, brainstorming sessions,workflow, and fishbone analysis

Weekly team meetings

Intervention

Data analysis

CS&E presentation and graduation

Project Milestones

Background • Problem – Patients, nurses, physicians and care coordinators do not communicate effectively about

discharge dates, times, and needs resulting in delays in the discharge process

– Issues with midday discharge bottleneck and geographic localization

– Discharge planning begins upon admission; much of work waits until patient is nearly ready to leave. National Benchmark for Medical Surgical Unit Length of Stay (LOS) is 5.2 days

– Recommendations: revisit morning rounds; use of anticipate discharge orders

• Literature – Anticipated discharge orders written 1 – 2 days prior to actual discharge date allow care teams to support scheduled times for discharges and reduce length of stay*

– Emergency Department LOS independently predicts excess inpatient LOS.

– Payors (e.g., CMS) look at LOS as a measure of cost control

– Hospital standpoint is shorter LOS allows for greater capacity and more efficient use of resources

– Patient/provider standpoint is short LOS demonstrates a streamline process

• Rationale – Use of anticipated discharge orders provide for effective communication among care givers. Patients and staff expectations for the time and date of the discharge are met. This allows for effective planning which promotes patient safety and improves the finances of the facility.

5ACU Patient Flow Process: Current State

“Anticipate discharge”

orders

5ACU Cause and Effect Analysis

“Anticipate discharge” orders

46 n=5

21 n=2

15 n=2

10 n=4 8

n=2 7

n=2 5 n=2 2

n=1 1

n=1

40%

58%

71%

80%

87%

93% 97% 99% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

5

10

15

20

25

30

35

40

45

50

Patient/Family -Funding/Financial

Limitations

Patient/Family -Severity of Illness

Physician -Scheduling delay

Other UHS - ServiceDelivery -

Endoscopy

UHS - ServiceDelivery -Radiology

InterventionalRadiology

Cath Lab, Other Patient/Family -Unavailable

Cu

mu

lati

ve %

# o

f A

void

able

Day

s

Types of Reason for Avoidable Day

Avoidable Hospital Days, 5ACU October 2014 - February 2015

(n = 21)

# of Days Cumulative %

5 SW planning • 4 renal patients

2 w/ dialysis needs 2 ESRD, no dx

• 1 no med. bft

Source: Allscripts, Avoidable Days Report

“Anticipate discharge”

orders

Action Plan

Action Strength Action Who When Status Weak – additional study Pre-survey Kana/Mario

3/6 Complete

Weak Strong – standardization of process through training

Education and Training House staff Nurses CC/SW

Kana Mario Jerry

3/2-3/15

Complete

Intermediate – software enhancement

Concurrent coding/UR Mario 3/2-3/15

Complete

Strong – standardization Anticipate Discharge orders- daily list

5ACU Charge Nurses

3/16 In progress

Strong – standardization JBI MD RN CC/SW

Kana Mario Jerry

3/6-3/15

Complete

Strong – tangible involvement and actions

Discharge planning mtg- 2pm daily for pts for d/c in AM

5ACU Charge Nurses MD Team s CC/SW

3/16

In progress

Statistical Process Control Chart – p chart - Process

Pre - intervention

84%

100%

LCL

34%

0%

20%

40%

60%

80%

100%5

/1/2

01

45

/2/2

01

45

/3/2

01

45

/4/2

01

45

/5/2

01

45

/6/2

01

45

/7/2

01

4

Wee

k 1

Wee

k 2

Wee

k 3

Wee

k 4

Wee

k 5

Wee

k 6

Wee

k 7

Wee

k 8

Wee

k 9

% C

om

ple

tio

n o

f A

nti

cip

ate

Dis

char

ge O

rde

rs

5ACU Anticipate Discharge Order Compliance (Intervention: 3/16/15 - 5/17/15)

UCL = 100%

CL = 60%

Post - intervention

UCL = 49:40:57 48:26:43

CL = 14:07:30 19:59:21

LCL

2:42:43

14:42:43

26:42:43

38:42:43

50:42:43

62:42:43

3/2

/15

3/3

/15

3/4

/15

3/5

/15

3/6

/15

3/8

/15

3/9

/15

3/1

0/1

53

/11

/15

3/1

2/1

53

/13

/15

3/1

4/1

53

/15

/15

We

ek 1

We

ek 2

We

ek 3

We

ek 4

We

ek 5

We

ek 6

We

ek 7

We

ek 8

We

ek 9

Ave

rage

AD

O t

o D

C C

ycle

Tim

e (

hh

:mm

:ss)

5ACU Anticipate Discharge Order to Discharge

(Intervention: 3/16/15 - 5/17/15)

Pre - intervention Post - intervention

5.9

5.2

7.1

6.0 6.3

7.7

6.2

7.9

7.3

6.8

6.2

7.0 7.4

9.5

8.3

5.5 5.9 5.8

8.1

UCL=9.51

10.39

CL=6.6

7.07

LCL=3.77 3.75

0

2

4

6

8

10

May2014

Jun2014

Jul2014

Aug2014

Sep2014

Oct2014

Nov2014

Dec2014

Jan2015

Feb2015

Week1

Week2

Week3

Week4

Week5

Week6

Week7

Week8

Week9

Ave

rage

Le

ngt

h o

f St

ay (

Day

s)

5ACU Average Length of Stay: (Intervention: 3/16/15 - 5/17/15)

Pre - intervention Post - intervention

Statistical Process Control Chart – XmR – Clinical Outcome

Source: Report Manager, Report # 005.41

5ACU Total Discharges Histogram, 1/2 hr intervals (Intervention: 3/16/15 - 5/17/15)

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Pre-intervention

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Post-intervention

Sustaining the Results

Continued data analysis for periodic presentation to leadership and staff

Staff training integrating results

into continued rotations and

training

Advocate for all units to use ADOs

Soft Return on Investment

Hard Return on Investment: net return through revenue enhancement via increased number of cases & payment per insurers and increased revenue from additional payer sources, & net return through cost savings via decrease LOS.

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0:0

6:2

5

8:4

7:1

6

17

:28:

07

26

:08:

58

34

:49:

49

43

:30:

40

52

:11:

31

Nu

mb

er

Time (hh:mm:ss)

Pre-Capability Histogram ADO to DC Order Cycle Time 3/2/15 -- 3/15/15

n = 90

0

5

10

15

20

25

0

5

10

15

20

25

0:0

0:0

0

7:0

9:0

7

14

:18:

14

21

:27:

22

28

:36:

29

35

:45:

36

42

:54:

43

50

:03:

50

57

:12:

58

Nu

mb

er

Time (hh:mm:ss)

Post-Capability Histogram ADO to DC Order Cycle Time

3/16/15 -- 5/17/15 n = 420

Conclusion: A Systems Approach to LOS

Funding Barrier

UHS Inpatient Outpatient

SNF New

Contract Signed

Haven for Hope

Home Health

LTAC Negotiating NEW Contract

Ambulatory Clinics

Community Resources

Methodist ministries

Team Pictures

20

•http://www.ncbi.nlm.nih.gov/pubmed/14609414

•http://ajcc.aacnjournals.org/content/15/5/502.short

•http://www.mc.vanderbilt.edu:8080/reporter/index.html?ID=3030

•http://dx.doi.org/10.7182/pit2013226

•The effects of anticipatory discharge orders on length of hospital stay in staff pediatric patients Sumer T,Taylor DK,Mcdonald M;Mckinney

V.,GillardM,.Grassel K.,KpalnW.,KherehllahN. AJM QUAL 1997 Spring:121 (1) 48-50

•2015 Vanderbilt University Medical Center, VUH to Improve patient discharge; Paul McGovern 2015

References