1. October 23, 2012 1 It takes a Team A multidisciplinary approach to managing hospital entry points Presented by: Maria Antonucci, MS, RN and Susan F. Byrd, RN, BSN, CEN

2. 1926 - American Legion Hospital for Crippled Children All Childrens Oct. 1, 1967 All Childrens Hospital History All Childrens Hospital Opened Jan. 9, 2010 April 4, 2011: ACH integrated with Johns Hopkins Medicine 2

3. 738,000 Square Feet 259 Inpatient Beds 97 Bed NICU -35 Bed Level II -62 Bed Level III ACH Heart Center -22 Bed CVICU -2 Cardiac Operating Rooms -3 Cath Labs -Interventional Radiology Suite 28 Bed PICU Vincent Lecavalier Pediatric Cancer and Blood Disorder Center -28 Bed Unit: BMT, Positive Pressure Floor 12 Operating Rooms & Special Procedures Unit Outpatient Care Center (OCC): 250,000 sq ft: physician offices, diagnostic services, laboratory, Ronald McDonald House, Conference Center, administrative offices All Childrens Hospital Opened Jan. 9, 2010 All Childrens Hospital 3

4. Source: ACHS Operating Indicators Report All Childrens Hospital FY2012 Statistics 4

5. All Childrens Hospital Top 10 Specialties by Discharge FY2012 5

6. 100 Day Workout Methodology Supports focus on Pursuing Perfection goals to improve Service, Outcome and Cost Action-oriented change model: Rapid-Cycle Testing (RCT) Utilizes Lean Six Sigma principles with Just-In-Time (JIT) training Brings together teams of managers, frontline staff and physicians Improvement ideas and actions plans from teams Establishes accountability –Kickoff, 30-60-90 day check-ins, Summation –tool for tracking change ideas and results

7. What is Lean Six Sigma? –A combination of two process improvement methodologies: –Lean involves removing wastes from a process –Six Sigma involves reducing variation in a process

8. Patient Flow Workout Right patient, right bed, right time 60 minutes or less

9. Hospitalist as Gate Keeper Strategies for Improving Inpatient and Observation Bed Utilization for Patients Admitted Through the EC

10. Goals Improve utilization of inpatient beds Decrease the % of reclassified patients to less than 10% Improved utilization of CDU beds Improve patient placement on all referrals to hospitalist service Improve collaboration between hospitalists and EC physicians in the ongoing care of patients not ready for discharge from the EC

11. Rapid Cycle Test Routed direct admits with reduced length of stay to EC Had Hospitalist determine next level of care – Clinical Decision Unit – Observation – Inpatient

12. RCT Outcome

17. What we learned… Slight decrease in patient categorized as observation No real change in Emergency Center time in department indicators Less rework for case management correcting patient status Difficulty with Hospitalists staffing

18. CM patient flow workout Correct assignment of patient type on admission –Noticed a large number of emails to change status –Most were inpt to obs –Drilled down the obs status –Only 2 status available –Decision to collaborate with teams –Multiple access points identified

19. Would Case Management in the EC be a better gate keeper? Would it help meet the needs identified in the CM patient flow workout? Back to the drawing board…

20. Assumptions If patients have correct assignment of status upon admission: –Right patient in right bed –Increased utilization of CDU –Decrease rework for status change/lean process

21. Access case management Role includes all the functions of the current hospital case managers with the focus being on patients at the point of entry into the hospital.

22. Hospital entry points Emergency Center Direct Admits Transfers Same day surgery

23. How do we get there? ROI for EC Case manager

24. What can they do? An Access Case Manger can prevent inappropriate admissions, improve discharge planning, decrease cost and enhance patient satisfaction. They can decrease utilization of the EC for non- emergent visits, promote the use of community resources and improve discharge planning to avoid excessive costs.

25. EC CM staffing plan Success = staffing 7 day/week, 12-hour/day (1100- 2300hr) Salary range average is $34/hr. 2.1 FTEs = $148,512 + benefits

26. Revenue Opportunity The LOS = 5 days for non ICU. Medicaid reimbursement is $2765.69. One inappropriate admission would cost $8295. One/week/year would cost $431,340. Potential to avoid one inappropriate admission per week = $431,340 2.1 FTE case manager salaries per year = $148,512 Net revenue = $282,828

27. Opportunity for increase in patient satisfaction, staff satisfaction, quality of care patient flow, bed turnover… PRICELESS!!!

28. Goals of position: The access case manager will be based in the EC working with the multidisciplinary staff in developing a plan of care for the patients. They will be a resource in the decision making process care as it pertains to possible admission.

29. Other functions Facilitate patient flow to correct bed Facilitate and expedite testing Implement EC discharge planning Follow up phone calls Patient rounds

30. Where are we today Have 2 positions filled Learning to navigate through the EC Learning First Net Identifying process Full roll out planned

31. Next steps Tackle direct admissions Entire patient placement center collaboration

32. Questions ? Thank you for listening!