1. 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.

2. 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.

3. 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

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

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

6. 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 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.

7. 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.

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

9. 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

10. 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

11. Reviewing Post-Discharge Lab Results

12. Returning Patient Calls

13. Following-up LWBS Charts

14. 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

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

16. 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.

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

18. Analyzed Historical Data to Quantify F/U Workload
Dates
Sample Size
List of LWBS Patients
12/1/ /31/2016
124 patients
AES: 121 patients
CES: 3 patients
ED Labs
1/1/ /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

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

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

21. 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

22. 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 voic to contact patient

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

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

25. 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

26. Summary of Reviewing Post-Discharge Lab Results
AES: 76% of labs
CES: 24% of labs
Each lab review process takes 10 +/ 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

27. Returning Incoming Calls

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

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

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

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

32. 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.

33. 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,

34. 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

35. Following-up LWBS Charts

36. LWBS Volume in December 2016

37. 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.

38. 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.

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

40. 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.

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

42. 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%

43. 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%

44. 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.

45. Standardized Documentation

46. 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

47. 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.

48. 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.

49. 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

50. Thank You !