Transcript Transitions with a BOOST

Transitioning Care
Matthew Schreiber MD
Chief Medical Officer
Piedmont Hospital
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What Ails Medicine Today
 Uncontrolled and Unsustainable Costs
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Unplanned Re-hospitalizations cost Medicare
$17 – 20 Billion per Year
 Inadequate Outcomes
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Approx 1 in 5 General Medicine patients are
readmitted within 2 weeks of discharge
 Work-Force Shortage and Intense
Dissatisfaction
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The Solution
Make People Happier to Do More Work Better
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Making People Happy—The
Current State
 Today Is Going to be a Crappy Day—we’re
understaffed and overworked and no one
cares
 I can’t find the doctor, he doesn’t know the
patient and they seem to change every day
 No one takes ownership of the problem. . .
 I can’t get the testing that I need when I need it
 Communication and handoffs are abysmal
 All anyone Cares about is money
 It seems like it takes management forever to
fix the problems
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Hospitalist Ward Organization
 Have you ever thought the world would be a better place if
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only everyone would let you call the shots?
Have you ever thought why am I doing job x when person y is
really expert in that? Or why is person y doing what I could
really do best?
Have you ever had the experience that no one completed the
task that was everyone’s job?
Have you ever found out the hard way that no one was
responsible for something important?
Have you ever felt that the patient was getting in the way of
our care process?
Have you ever felt the rhetorical questions would never end?
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Hospitalist Ward Solutions
 If you ever have a problem, ask the people that do the work—they have
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all the answers
You cannot buy, contract, or write a job description that will get you
beyond good
Amazing things happen when you tap into “mission motivation”, and
collaborate with exceptional individuals to reach a common goal
People in health care are superior people—every single person in
healthcare could probably earn more for doing less in another field—yet
here they are
Taking exceptional care of people is the best business plan
We are our greatest asset—the best recruitment plan is a retention plan
Always ask what can I contribute to the solution, no matter how small
that may be
Outcome orientation—we WILL produce the best results because there
will be no “effort dependent failures”
Focus on post discharge services and phone follow-up—responsibility
for the outcome does not disappear when the patient disappears
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“Unique Mechanics”
 Geographically designated personnel including IMS MD—LEAN
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Advantage
Ward organized around attending MD instead of disease state
Name in the Box*
Right person, right job***(eg pharmacy)
Centralized Communication—d/c criteria, what’s next, patient out
of room on “public” whiteboard
Automation/Standardization—data retrieval results in predictable
responses
Detailed Risk Assessments translate into proactive care—
medications, functional assessments
“Specialized testing triage”
Create “the Pull”
Charge RN in Charge of being in charge
BOOST toolkit
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 Identify and Risk Stratify For Discharge
Failure
 Intervene with focused care
 Educate/Inform the Patient AND Key Contact
 Written Discharge Action Plan that
Patient/Caregiver can “Teach Back”
 Follow up with 72 hr call, home health,
provider visit
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$50 White Board with the $1
Million Impact
 Main Whiteboard in RN Station
Rm#
Name
Transitions DOA
LOS* Age
Dx
PCP Symbols
 Pt Room Whiteboard
Day/Date
RN for
shift and
station #
Charge
RN
Name
How to
Call into
RM
Key Fam
Contact
and #
IMS MD/# Consulting How to
MDs
Call
Dietary
Plans for
Day: Dx,
tests,
results
Dispo info
PCP
name &
f/u
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The Outcomes—Making People
Happy
 I’d rather see 20 patients like this than 15 patients the old way
 I can discharge so many patients because I know there are no
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loose ends
When did all the IMS MDs get their lobotamies? They are so
nice and so responsive now. It’s great having them always
around
When did the nurses get their lobotomies? They are excellent—
so well informed and so helpful—they make sure everything
goes right and they will take great care of our patients
Significant Increase in Patient Satisfaction
Why don’t I have a board like this in my room? It’s awesome
The IMS Unit was the only place where the charge nurse could
tell you about the status and discharge readiness/plan for every
patient [Happy Administrators]
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Doing More Work With the Same
People
 The number of Bed Turns Doubled compared to the
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same period on the same unit the year prior
The number of bed turns is 2x higher than the next
most efficient unit in the hospital
Acuity particularly for nursing care much higher
Nurses going to get patients from the ER/ICU
Additional Duties like hanging own blood, rounding
with MDs
Staffing remained based on midnight census as
compared to bed turns
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Doing Better Work
 Higher patient Satisfaction
 Higher Staff Satisfaction—nursing, IMS, ancillary
 Much Better Communication with Home Health and PCPs.
 Appts made prior to discharge
 Much Higher rate of pt understanding and “teach back”
 RCA attitude for any readmission in 72 hrs
 Reduction in Readmission Rate
 Better PCP Satisfaction
 Lower rates of specialized testing cancellation
 Dramatic reduction in medication errors
 Earlier D/C times leads to earlier ICU transfers which “unloads”
whole house patient flow backlogs.
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The Bottom Line
 FY ’09 IMS goal to reduce Variance days by 15% was seen as a very
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aggressive goal
IMS Unit reduced Variance Days by 66% after 1 yr of service!!
Absolute reduction of 545 days. Variance days per case was 1.19, now
0.12 [18 mos]!! 6C went from 0.94 to 0.4 Var day/case in 12 mos and
5N went from 0.76 to 0.51 in 6 mos.
This allowed PH to care for an additional 110 pts without adding any
beds or staff on 6N alone. Average hospital COLLECTIONS for an IMS
pt is $9,800 implying an addition to net collections of over $1million.
Functional equivalent of adding 1.5 hospital beds
This one unit palpably changed whole house pt flow.
Readmissions decreased: < 70 pop readmit rate 3.97% vs 13.05%;
> 70 11.17% vs 15.9% While CMI went from 1.3 up to 1.45 and LOS
declined
4% Improvement in RN retention
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Dramatic decrease in costly medication errors
All I Ever Needed to Know About Fixing
American Medicine I Learned in Daily Life
 Do Unto Others—Patient Centered Care
 You Never Knew So Much About the Wheel Until you Tried to
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Reinvent it
Do Something Different Wrong—Doing things the way you’ve
already done them won’t get you anywhere different from where
you are
If You Want a Solution that Works, Ask the People that Live with
the Problem
Taking exceptional care of people is the best business plan—
“No Mission No Margin”
The best recruitment plan is a retention plan
Match the job to the person who can do it best
Genius Tends to be Elegant
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Creating Safe Discharges is Like
Being an American In the Stock Market
 We all know the job—Save for retirement
 We’re offered some excellent tools (401K)
 There is a ton of information out there
 It confuses the experts
 No one and everyone “owns it”
 Success depends on getting the basics right
and on doing the maintenance work between
decision points
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Eminent Domain
 Medicine Has Focused on Episodes and
Domains of Care and Responsibility
 We Need to Focus not on how well we did
“our job” rather on patient outcome
 We are all responsible for the whole shebang,
though we choose to subdivide responsibility
for our own convenience
 Make the Most of the “Inpatient Moment”
 We Already Have All the Help we need to
cure what ails medicine—it is sitting in this
room
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