UM Emergency Department (ED) Analysis of Current Follow-up Process Final Presentation IOE 481 Project Team 6 Joy Chang Zian (Shawn) Cheng Bailey Haydock Rachel Ryan Introduce ourselves… And we are team six. During this presentation, we would like to outline our project proposal of the analysis of the current follow up process at the Emergency Department. I will go ahead and let the team introduce themselves.

Agenda Goals & Objectives Methods Process Flow Maps Findings & Conclusions Recommendations Expected Impact As a reminder, our team has been working closely with the ED follow-up team to investigate and improve the follow-up process. The follow-up process was designed to handle the contact and communication with patients about significant lab results and proper treatments post visit. So, the follow-up nurses are responsible for contacting patients about lab results and returning patient phone calls from M-F 7a-7p. On off-hours and weekends, charge nurses will return incoming patient phone calls.

Goals and Objectives Goals: Define the current follow-up process in the ED Investigate the efficiency of the current staffing model Objectives: Document current process By documenting the F/U process with process flow maps we will be able to identify areas of improvement. And by capturing the F/U workload in metrics such as process time, volume of calls received by F/U and charge nurses, timeframe of incoming calls and returning calls, and peak times patients call into the ED, we will be able to make staffing model recommendations. Identify areas of risk Capture follow-up (F/U) nurse workload

Methods Perform Literature Search Conduct Interviews & Observations Perform Time Studies & Collect Data Analyze Historical Data To approach this project we,

Methods Perform Literature Search Conduct Interviews & Observations Perform Time Studies & Collect Data Analyze Historical Data

Benchmark: Staffing Model Stony Brook University Medical Center 2 full-time RNs, 2 part-time RNs 365 days/year, 10 hours/day 50-60 patient follow-up calls/day Michigan Medicine 2 full-time RNs, 1 part-time RN 250 days/year, 12 hours/day ~30 patient follow-up calls/day To benchmark alternative ED follow-up processes and staffing models, we performed a literature search. Using one source we found that Stony Brook has a similar F/U process and staffs two full-time and two part-time registered nurses for 365 days a year, 10 hours each day. This staffing model allows the follow-up team to make 50-60 patient follow-up calls daily. On the other hand, Michigan Medicine staffs 2 full-time and 1 part-time RN for 250 days/year, 12hours per day. This follow-up team makes about 30 calls daily. Therefore, we will use this benchmark to drive improvements to the ED’s current staffing model.

Benchmark: Average time for follow-up call University of California, San Francisco 10 minutes Michigan Medicine 10 ± 6 minutes Moreover, a study from the University of California, San Francisco indicates the average time for a follow-up call to be 10 minutes per call at UCSF Medical Center. We will consider this time as a key performance indicator to quantify F/U work.

Methods Perform Literature Search Conduct Interviews & Observations Perform Time Studies & Collect Data Analyze Historical Data

Interviewed IT for Filtering Lab Results Logic Key Finding: As long as the patient has been discharged from the ED, any post-discharge labs will be sent to the F/U in-basket Key Conclusion: No risk of lab results not being reviewed

Observed F/U Nurses to Develop 3 Process Maps 32 hours of observations January 23 - February 2, 2017 Primary Follow-Up Tasks: Reviewing Post- Discharge Lab Results Returning Incoming Calls Following-up LWBS Charts Define current follow-up process as 3 primary tasks Left Without Being Seen Patients (LWBS) Incoming phone calls from post-discharge ED patients Post-discharge lab review Document each task with a process map Observations and interviews

Reviewing Post-Discharge Lab Results

Returning Patient Calls

Following-up LWBS Charts

Interviewed Charge Nurses to Identify Inconsistencies 9 charge nurses (3 CES/6 AES) Asked nurses to estimate time length of calls, and to describe their follow-up process and the impact it has on their work AES CES Not standardized process Inconsistent documentation Distractive environment Not standardardized process Time consuming AES: Not standard process bc Inconsistencies between actions taken after patient call received. CES: time consuming bc have to look patient up by MRN number...dont have access to same info as follow up nurse and effects placement of CES children if on the phone Distractive environment bc they take the calls at the public desk unlike follow-up nurse

Methods Perform Literature Search Conduct Interviews & Observations Perform Time Studies & Collect Data Analyze Historical Data

Collected Data to Capture Process Step Times Data collection period: February 27 - March 20, 2016 Modified F/U nurse written logs by adding time columns Number of Incoming Calls: 246 Number of Lab Results: 198 Lab logs and incoming calls log from charge nurses What information: type of lab, start/ end times on most occasions, lab result, etc.

Methods Perform Literature Search Conduct Interviews & Observations Perform Time Studies & Collect Data Analyze Historical Data

Analyzed Historical Data to Quantify F/U Workload Dates Sample Size List of LWBS Patients 12/1/2016 - 12/31/2016 124 patients AES: 121 patients CES: 3 patients ED Labs 1/1/2016 - 12/31/2016 2136 post-discharge labs AES: 1580 labs CES: 556 labs Follow-up Data 532 patients AES: 376 patients CES: 152 patients Did not have access to the data which covered the same weeks as the lab logs Had about a month's worth of historical data

Findings & Conclusions Reviewing Post- Discharge Lab Results Returning Incoming Calls Following-up LWBS Charts Identified 3 key components and responsibilities of charge nurses

Reviewing Post-Discharge Lab Results Lab review- any abnormal results, “scrubbing” the chart, staffing, following up as necessary, etc.

Reviewing Post-Discharge Lab Results Process Map 5.8 +/- 4.9 min Interviews, observations, and analysis of nurse lab logs= identification of key steps and metrics We’ve established a thorough version, but for simplicity of understand this flow chart identifies the Key steps of the process: Review chart- 4.1 min Consult with staff- 5.8 min Patient contact if needed Make michart note WHOLE PROCESS TAKES 10 min avg

Reviewing Post-Discharge Lab Results Process Map 5.8 +/- 4.9 min Although no time study on the duration of patient contact calls due to limited availability of data We were able to identify 33% of lab reviews require patient contact Of these, 59% of patients could be reached on the first attempt 20% on the second attempt 21% required a voicemail to contact patient

Lab review is completed in 10 min on average -due to lab types -due to the number of calls for patient contact

Significantly more lab reviews occur on Mondays **double coverage 12 hours on monday **double coverage 4 hours on wed ^reflected in the graph

On average, 35.8 non-normal labs result on weekends **reason for large volume monday is due to the large number of labs that result and must be reviewed from the weekend carry over to monday ****Patient Risk

Summary of Reviewing Post-Discharge Lab Results AES: 76% of labs CES: 24% of labs Each lab review process takes 10 +/- 11.4 mins on average ⅓ of all labs reviewed require patient contact Monday has the most lab results (37 labs avg) 35.8 non-normal lab results occur on weekends

Returning Incoming Calls

Returning Incoming Calls Process Map Here’s a simplified version of incoming calls process map.

Returning Incoming Calls Process Map Notice that the standard deviation are quite large because of the nature of incoming calls.

AES Volume of Phone Calls Peak occurs at noon and 7 PM to 10 PM has a lot of calls as well

CES Volume of Phone Calls 7 PM to 10 PM has a lot of calls coming in as well

AES Call Volume AES accounts for 70% of total calls Sundays: 5% Saturdays: 10% M-F 10p-7a: 10% M-F 7p-10p: 9% M-F 7a-7p: 71% AES accounts for 70% of total calls 71% of AES calls arrive during F/U nurse hours The calls could also be divided into either: AES or CES. AES means adult and CES means children. AES accounts for 70% of total calls. Blue region covers 71% of the chart, meaning that 71% of AES calls are captured by the follow up nurses. Yellow region represents the calls that come in when nurses are not working. On the weekend, Saturday is like doubling the volume of Sunday’s volume Tableau data from December 1st to 31st.

CES Call Volume CES accounts for 30% of total calls M-F 7p-10p: 14% M-F 7a-7p: 61% M-F 10p-7am: 9% Saturdays: 10% Sundays: 6% CES accounts for 30% of total calls 61% of AES calls arrive during F/U nurse hours CES calls are more spread out than AES: the yellow region is larger than the AES version. Blue region covers 61% of the chart,

Summary of Incoming Phone Calls AES: 70% of calls CES: 30% of calls 16 mins on average before the nurses to return the call 17 mins on average to do a call 21.87 hours (not including chart reviewing time and call preparation time) are spent on doing calls weekly on average 7 PM to 10 PM would be a great time period to cover Saturday has about twice the number of incoming calls of Sunday CES calls are more spread out throughout the time

Following-up LWBS Charts

LWBS Volume in December 2016

On average, 9 LWBS cases result over the weekend and must be reviewed on Monday Left Without Being Seen, or LWBS, patients are patients who have been triaged but leave the emergency rooms after triage before the doctor sees them. Follow-up nurses are required to review all LWBS patient charts and triage in case the patient has a critical condition. Since the F/U nurses are not staffed on the weekends, LWBS charts can go 3 days without being viewed by an hospital personnel. On average, 9 LWBS cases wait 3 days before review; in the worst case, 19 LWBS cases waited 3 days.

Summary of LWBS Charts AES: 98% of LWBS CES: 2% of LWBS 25% of LWBS cases needed follow-up in December On average, 14 +/- 15 minutes to call LWBS patient On average, nurses spend 2 hours a week contacting LWBS patients Maximum LWBS cases in one day is 19. Minimum LWBS cases in one day is 0. On average, 9 LWBS cases result over the weekend.

Staffing Model Analysis Summary and Recommendations We will now provide a summary of our staffing model analysis and recommendations to mitigate risks we found.

Staff a Follow-up Nurse on Saturdays Based on our analysis, the biggest risk in the current follow-up process is that no follow-up nurses are staffed on the weekends. As you can see on the chart to the right, significant volumes of work accumulate over Friday, Saturday, Sunday. This creates significant patient risk since many of these charts, labs, and calls contain critical patient information that may require immediate action, but either no one reviews them for an entire 3 days. The primary staffing priority should be to staff a follow-up nurse on weekends. We have identified 9am - 3pm on Saturdays as the best time to staff. In doing so, we can shrink the time that patient cases are unreviewed and we can cover 6% more AES calls and 5% more AES calls.

Saturday Call Volumes Staff a F/U nurse 9am - 3pm Cover 6% more AES calls Cover 5% more CES calls

Altering Mon-Fri Shifts to Capture More Calls Overall Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm 8am-8pm 9am-9pm % Calls Captured 81% 85% 86% AES Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm 8am-8pm 9am-9pm % Calls Captured 83% 87% CES Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm 8am-8pm 9am-9pm % Calls Captured 75% 82% 83%

Impact of a Part-Time Nurse Mon-Fri Overall Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm % Calls Captured 81% 7pm-10pm 12% 7am-10pm 93% AES Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm % Calls Captured 83% 7pm-10pm 11% 7am-10pm 94% CES Calls Captured Mon-Fri in a 12 hour staffing window Staffing Window 7am-7pm % Calls Captured 75% 7pm-10pm 14% 7am-10pm 89%

Do Not Separate AES and CES Staffing CES workload requires at most one follow-up nurse Staffing to cover high % of CES phone calls requires 2-3 F/U nurses At this time, we believe the priority is staffing critical windows and making sure a follow-up nurse is available for critical points throughout the week. Separating AES and CES staffing would be extremely difficult, for a few reasons. The current CES workload is only 30% of the current follow-up process, and would require at most one additional follow-up nurse. If staffing was completely, to cover the same 80% of calls, previously suggested in the staffing model, the task would require 2-3 CES only nurses. The volume for CES is low, but it’s extremely spread out - notice that the orange line in the graph has peaks and hills for calls just about every hour of every day.

Standardized Documentation

Charge Nurses Need a Standard Method for Documenting Patient Calls in MiChart CURDI Acronym for Standard Documentation Concern. What is the patient’s concern? Understand. Ask follow-up questions to understand the patient’s concern. Re-triage. Re-triage the patient’s condition. Direct. Direct the patient on next steps to take. Intent. Have the patient verbalize their understanding of instructions and intent for their next steps. -interviewed 9 charge nurses, they all had different methods for documenting notes in michart, weren’t completely sure what they were supposed to document -WHY? To avoid inconsistencies, to improve quality of care for patients

Standardize Discharge Information to Reduce Follow-up Rework Call Type Duration (Minutes) Time Spent Per Week (Hours) Patient 10 ± 6 7.3 Pharmacy 15 ± 10 2.25 LWBS 14 ± 15 2.1 Occupational Health Services (OHS) 11 ± 17 2.2 Radiology Addendum 27 ± 27 Worknotes 26 ± 36 1.73 The F/U nurses currently handle a wide variety of issues and questions from patients regarding their post-discharge care. Based on call type data in Table 2, the team saw that pharmacy related calls required 2.25 hours/week, work note-related calls required 1.73 hours/week, and general patient calls required 7.3 hours/week. To some degree, the amount of time for each type of call can be significantly reduced if patients better understand their post-discharge care.

Standardize Discharge Information to Reduce Follow-up Rework The nurse should ask the patient the following questions at discharge: Do you have any questions for the medical staff? Do you have any questions about your prescriptions? Do you need a work note? To help patients better understand their post-discharge care, the team recommends that staff nurses ask a standardized set of questions when discharging patients. This standardized set of questions can resolve patient misunderstandings immediately and save both the patient’s and ED’s time to go back over the questions.

Expected Impact Clear documentation of the current follow-up process Awareness of areas of improvement Improved quality of care for patients Enabling F/U nurses to safely support more patients Documenting notes in MiChart consistently

Thank You !