Transcript prework - RegOnline

Prework for D2D Workshop
LWOT Problem Tool
Quotes
Surge
Scenarios
LWOT
LWOT
Problem?
1
The EXCEL® Tool 1
Quotes
Surge
Scenarios
LWOT
Purpose: Calculates Past Average LWOT% per Month. Plots Past LWOT% Vs. Patient Volume.
LWOT
Problem?
Directions:
1
LWOT Problem?
Macros must be enabled. First, click the "Clear Data" button to clear the default data. Then, input the month,
monthly number of patients that Leave Without Treatment (LWOT), and the total number of patient visits including
LWOT in the table below. Fin
OUTPUT:
Clear Data
Month
Jan-04
Feb-04
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Analyze Data
Historical Information
LWOT#
Total Patients LWOT%
710
8037
8.8%
1105
8154
13.6%
673
7761
8.7%
396
7177
5.5%
254
7284
3.5%
253
6956
3.6%
202
7012
2.9%
315
7351
4.3%
419
7523
5.6%
335
7531
4.4%
367
7480
4.9%
446
7802
5.7%
983
8837
11.1%
1103
7986
13.8%
1130
8557
13.2%
1341
8314
16.1%
1307
8284
15.8%
730
6977
10.5%
703
7027
10.0%
808
7356
11.0%
588
7431
7.9%
658
7740
8.5%
634
7622
8.3%
1742
8842
19.7%
LWOT#
Average per Month
717
Fit Performance
R2
-30%
LWOT%
Patient#
9.1%
7710
Red if R2 < 35%.
Queuing Prediction Curve of LWOT[7]
3000
25%
2500
20%
2000
LWOT#
INPUT:
15%
1500
10%
1000
5%
500
2%
0
0
2000
4000
6000
Total Patients
8000
10000
12000
Minimum Volume
Requirement Tool
Volume
≥ Min?
2
Acuity Split
Hourly Peaking
The EXCEL® Tool 2
Purpose: To determine whether a facility has sufficient volume to support a separate Intake/Discharge area
INPUT:
Daily Planning Volume
(Including LWOTS)
233
Acuity:
Level 1 (f1)
0.03%
Level 2 (f2)
8.28%
Level 3 (f3)
68.73%
Volume
≥ Min?
Level 4 (f4)
20.53%
2
Level 5 (f5)
Sum (must equal 100%):
2.18%
100%
OUTPUT:
Annual Planning Volume
85045
Peak
Hourly
Time of Day
Multiplier ED Arrivals
Peak Period (9am-9pm):
1.30
12.6
Acuity Split
Hourly Peaking
Arrivals/Hr to
Intake/Discharge
22.8
← In this cell, Green indicates that at least one Intake
provider is required (several may actually be required).
If the cell is Red, then volume is insufficient.
NOTE: Assumed average length of stay in Intake = 15 min., average length of stay in Discharge = 7.5 min.
D2D Care Process Tool
Flow
Chart
A
Care Process
Acceptance Goals
• With this tool, the user will be able to
answer the question: “How would our
current Emergency Department (ED) care
process need to change to implement the
Door to Doc (D2D) Care Process?”
• This acceptance assessment is based on
two exercises: a walkthrough and a
flowchart comparison of current ED
processes to the D2D Care Process.
Door to Doc Care Process
3. Patient
escorted to
Intake Space
(RN or Tech)
4. MSE/focused
assessment, Orders
& Documentation
(RN and Physician)
5. ED Bed
Required?
No
6. Diagnostic
Testing Required?
8. Medical
Imaging
B
9. Procedure/
Treatment
Yes
“Less Sick” Patients
7. Specimen
Collection
A
Intake (ESI 3- 5*)
No
Patient
Arrives
1. Quick
Reg (PFS
Rep) and
Quick Look
(RN)
“Sicker” Patients
2. Sicker?
(ESI 1 or 2)
10.
Move patient
to Results
Waiting Area
13.
Patient
escorted to ED
Bed
*ESI-Emergency Severity Index
11.
Review of
Results
19.
Patient to
Discharge
Room for
Informed
Discharge
12.
Medical
Decision
Making
20.
Patient to IP
Unit/IP Holding
Unit
14.
MSE/Focused Assessment,
Orders, Specimen Collection,
Procedure and
Documentation
(RN, Tech, Physician)
Full Registration & Co-Pay
Collection
(PFS Rep)
Patient
leaves the
ED
21.
Transfer to
another facility
18.
Patient
Remains in ED
Bed
Yes
Acute (ESI 1- 2*)
A
B
No
No
15.
Testing
16.
Treatment
17.
Patient meets
Results Waiting
Criteria
Yes
B
Your Current ED Process Flow
To be sure you know how your current ED process
operates, do a “Walk-Through”
Tips for Your Walk-Through
• Start with patient entry into the ED and end with the patient leaving the ED
• Include two to three people, if possible, with each viewing the process through the
eyes of a nurse and physician, patient and physician, etc.
• Conduct walk-through at different times of the day, days of the week
• Make a point of noting the paper trail of charts, lab reports, referrals, transfers,
medications, etc along that accompany the process steps
• At different steps ask the staff to tell you about the process step
Questions to Ask
•
•
•
•
Is this a busy or slow time?
How long on average does it take to complete a process?
Is the current process working well for patients and the staff?
Is the staffing level the same 24/7?
Use this information to construct a “high-level” flow
diagram of the current process
• Use ‘sticky notes” on a large surface in a group setting to identify and arrange the
steps before drawing it on paper
Patient Arrival Process
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Start with the first steps as the patient arrives
at the ED.
Check the box that best describes the
magnitude of the change.
Step
Description
Possible Changes
Staff Affected
1a.
Quick Registration
-Patient Accounting system accommodation for
‘Quick Registration
-Arrangements to complete registration later in care
process
-Patient Registration co-located with Quick Look
Patient Registration or
Business
Representatives
1b.
Quick Look
-Eliminate triage
-Co-location with Quick Registration
Nursing staff,
particularly Triage
Staff
2.
Sicker?
-Adopt “quick look” methodology (such as
Emergency Severity Index) for identifying sicker and
less sick patients
Nursing staff,
particularly Triage
Staff
3.
Patient Escorted to
Intake Space
-Not all patients taken to an ED Bed
Techs
BIG
Change
Medium
Change
Small/No
Change
Caring for “Less Sick” Patients
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Continue with the process for “less sick”
patients.
Check the box that best describes the
magnitude of the change.
Step
Description
Possible Changes
Staff
Affected
4.
MSE/focused assessment,
orders and documentation
-Jointly performed medical screening, rather than nursing
and physician separate
-Patient focused documentation (rather than separated by
provider)
-Eliminates mix of sicker and less sick patients increasing
the number of patients that can be seen by a physician
Physicians,
Nurses,
Techs
5.
ED Bed Required?
Physicians
6.
Diagnostic Tests Required?
-Handoff by physicians of patients who are determined to
be “sicker” after medical screening exam
n/a
7.
Specimen Collected
8.
Medical Imaging Performed
-Less sick patients move to these areas as directed on
their own
-Less sick patients move to these areas as directed on
their own
Ancillary
staff
Ancillary
staff
9.
Procedure/Treatment
Performed
-Less sick patients move to these areas as directed on
their own
Ancillary
staff
n/a
BIG
Change
Medium
Change
Small/No
Change
Caring for “Sicker” Patients
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Continue with the process for “sicker”
patients.
Check the box that best describes the
magnitude of the change.
Step
Description
13.
Patient Escorted to ED Bed
14a.
MSE/focused assessment,
orders, specimen collection,
procedure and documentation
14b.
Possible Changes
Staff Affected
n/a
n/a
Full Registration and Co-Pay
Collection
-Complete registration at bedside
15
Testing
n/a
Patient Registration
or Business
Representatives
n/a
16
Treatment
17
Patient ok for results waiting?
-Patients not requiring a bed moved out of
acute bed to results waiting
Physicians, Nurses,
Techs
18.
Patient Remains in ED Bed
BIG
Change
Medium
Change
Small/No
Change
Decision Making and Leaving
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the
change.
Continue with the decision making
process and leaving the ED.
Check the box that best describes the
magnitude of the change.
Step
10.
11.
12
19.
20
21.
Description
Move Patient to Results
Waiting Area
Review Test Results
Medical Decision
Making
Patient to Discharge
Room for Informed
Discharge
Patient to IP Unit/IP
Holding
Transfer to another
facility
Possible Changes
-Less sick patients don’t own a bed
-May involve handoff from original caregiver
-Utilize standardized approach for discharge and
completion of registration and co-pays as needed
-Separate location for discharge process
-May involve handoff of care
-Admitted patient care assumed by inpatient care
providers
n/a
Staff Affected
Physicians, Nurses,
Techs
Physicians, Nurses,
Techs
Physicians, Nurses,
Patient Registration
or Business
Representatives
Inpatient and ED
nurses, physicians
n/a
BIG
Change
Medium
Change
Small/No
Change
Next Step
• Review the results of the comparison of your
current process with the D2D Care Process.
• Now that you have identified the magnitude of
the changes that will be required to implement
D2D in your Emergency Department, the next
step is to determine whether the critical
success factors for acceptance of these
changes are in place.
Ready to
• Proceed to the next tool:
Change?
Survey
B
Definitions:
•
Quick Registration: Registration clerks collects only the information needed
to get the patient into the system (i.e. name, social security number, birth
date) and COA signed
•
Quick Look: The nurse only needs to document the chief complaint,
allergies and a set of vitals in some cases
•
Intake: Physician Medical Screening Exam including the H&P, review of
systems, physical assessment medical history as well as the questions that
nurses are required to ask including current medications, vital signs,
domestic violence, immunizations, pain assessment and skin assessment
•
IPED: The area of the ED for patients that need a bed during their ED stay
•
OPED: The area of the ED for patients that don’t need a bed during their ED
stay
•
LWOT: Patients who leave without treatment
•
ESI: Emergency Severity Index, an ENA triage tool to assign acuity of
patients using minimal data
Data Requirements
Month
January
February
March
April
May
June
July
August
September
October
November
December
Total number of
visits including
LWOTS
ESI Level
1
% of patients at Level 1
ESI Level
2
% of patients at Level 2
ED Acuity ESI Level
3
Mix
ESI Level
4
% of patients at Level 3
ESI Level
5
% of patients at Level 5
Ave Daily
visits
Number of Patients seen including
LWOTS
Admission
Rate
Number of Admissions/Number of visits
Quick
Look
How long does it take to do Quick
Registration and Quick Look (see
definitions above)
Intake
Average time for a Medical Screening
Exam/Nursing Assessment (see
definitions above)
OPED
Discharge
Average time it takes a provider for a
discharge (or "across the hall" transfer
order) from the OPED area
Number of
LWOTS
% of patients at Level 4
Stats
ED
Average
Times
Length of Test/Treatment (TAT for tests
and procedures)
LOH(Adm
it)
Length of Hold (Time for decision to
Admit to patient leaves the ED)
Overall
LOU
Length of Use (Time from patient arrival
to an ED room (IP or Intake) to decision
to discharge, admit or transfer is made)
Output Data Tracking
(to be filled in with outputs from the Toolkit)
Tool 3
Patient Arrivals per Hour
Quick Look
Intake/Discharge
Results
Waiting
Peak Period (9am - 9pm):
Off-Peak Period (9pm - 9am):
Overall Daily Average:
Tool 4
Area
Quick Look
Intake/Discharge
- Results Waiting
LOU - IPED
LOH (Admit) - Inpatient Transitional Care
Average Time
(min.)
Coefficient of
Variation
IPED
Inpatient Transitional
Care