1. AHRQ ANNUAL CONFERENCE Bethesda, Maryland September 26-29, 2010 1

2. Door to Doc Ochsner Medical Center 2

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4.  Intersections  Hurricane Katrina’s crossroads 4

5. Door to Doc  Intersections  Hurricane Katrina’s crossroads 5

6. Door to Doc  Intersections  Hurricane Katrina’s submerged crossroads 6

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14. Door to Doc  ED Crowding  Output (admission delays)  Throughput (non-lean workflow)  Input (poorly engineered demand management) “Martha, I am not feeling too well. Maybe we should go over to the ER and get triaged!!” 14

15. Door to Doc  Solve this problem 15

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17. Door to Doc  Cracking the code  Implement lean workflow Lean registration Lean triage  Create virtual capacity Door to Doc processing protects the most precious resource…..the bed Rules based process  Match resources to demand Queuing Theory Grocery Store Math © for EDs 17

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25. Door to Doc  Cost Analysis of LWBS  Net revenue (for real current LWBS payor mix) Outpatient facility net revenue @ $300/visit discharge (90% of visits ) Inpatient facility net revenue @ $5,000/visit admission (10% of visits) Professional provider net revenue @ $125/visit all (100% of visits)  1% LWBS @ 50,000 visits = 500 visits  Lost opportunity net dollars for every 500 visits that LWBS $135,000 facility outpatient revenue (450 pts x $300) $250,000 facility inpatient revenue (50 pts x $5,000) $62,500 professional revenue (500 pts x $125)  Cost of 1% LWBS at 50,000 volume = $447,500 25

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27. Door to Doc  Requires a leap of faith (1)  Unlocking old behaviors No registration up front and no deep dive triage  Dramatically different workflow for staff Reduce scarce real beds to create more virtual beds??????  Patient perspectives “ I never got a bed!” Privacy concerns  Physician issues No compensation benchmarks for this kind of work… and it is uniquely different EM MDs become internal customers…not comfortable position for them Not every MD suitable for D2D, requires great risk stratification skills 27

28. Door to Doc  Requires a leap of faith (2)  New roles to manage with odd job descriptions Flow techs and flow nurses  Administrative issues “Only the uninsured leave”…..not so Its not about the expense, its about the return (ROI)  Staffing paradigm shift MLPs and LPNs……may be perceived as threatening Forget FTE hrs/visit……think cost/visit  Rules! Lean processing at registration and quick look Intake beds must be protected at all cost…almost. Accountability for the WR Internal queuing always….not in the WR 28

29. Door to Doc Joe Guarisco MD FACEP jguarisco@ochsner.org 504-842-4433 29