Mercy Medical Center wanted to create the best experience for its patients. And its leaders wanted to make Mercy a better place to work for its physicians and staff.
The Springfield, Massachusetts hospital knew that achieving this vision meant removing bottlenecks that were affecting patient and work flow. To accomplish this, Mercy needed to eliminate the inefficiencies and variability throughout its system.
Mercy's leadership discovered that this would require a systemic transformation of their hospital operations — an initiative it called CareConnect.
The transformational shift any hospital must make to optimize operations begins with mindset change at the executive level. Rather than optimize operations around the hospital's capabilities —a common mistake that stems from a traditional hospital mindset — leaders must restructure operations around the patient's needs.
As hospitals like Mercy Medical Center set out to achieve and sustain a culture of operational efficiency, there are three critical ingredients.
1. Establish a culture of efficiency, including a system aim that clarifies the patient-centered focus
The first ingredient for total hospital operational efficiency is being clear about which outcomes the hospital aims to achieve.
A system aim creates a 'north star' for an organization, a clear statement of purpose. In Mercy's case it was to maximize the quality of the patient's experience so they selected, "together, doing the right thing, the right way, every day for every patient," as their system aim. This aim was then linked to the organization's goals, performance measures and operational milestones by asking, "in order to achieve this aim what goals must we accomplish?" They ultimately chose three, which became their key lagging performance measures.
- Improve overall patient experience
- Enhance quality of care and patient safety
- Achieve flawless execution and world class efficiency
Each department then participated with senior leadership in identifying cascading leading performance indicators that would ensure Mercy consistently accomplished their system aim. These were posted in each department and included in weekly operational rounding.
Mercy also established a daily "huddle" to ensure that the care team assessed each patient's clinical status, assigned a "working" DRG and a detailed plan to progress the patient toward an optimal discharge. The care team clarified and resolved obstacles to quality patient progression, or else escalated cases to leadership for prompt resolution.
Mercy also established weekly executive rounding to foster continuous performance improvement. All executive leaders rounded and discussed department level performance toward the key leading indicators. Department leaders and staff used A3 processes to efficiently clarify and resolve operational challenges. A3 rounding was first made famous by Toyota for use within its production system of continuous organizational performance improvement.
This culture of efficiency further encouraged hospital teams to function as a system, rather than as isolated teams and departments. Hospital executives were able to correct performance gaps immediately to ensure patient care and quality progression happen at the right time, in the right ways, with the right results.
Once a system aim and performance optimization infrastructure is in place, a hospital must add in systems engineering and logistics to achieve effective care coordination across all people and departments.
2. Build logistics into the hospital's care coordination model
Every day hospitals must simultaneously manage the input, throughput, and output of patients across a complex organization with many moving parts, prioritizing the use of limited resources, both human and diagnostic.
Hospitals, like Mercy, have applied a logistical "production model" approach to system-wide care coordination. This hub-and-spoke approach centralizes care coordination decision making to ensure reliable, predictable, and effective patient care and throughput.
There are several necessary steps required to effectively incorporate logistics into the hospital's care coordination approach:
1. Establish a clinical care coordinator role, which typically involves combining case management and charge nurse functions into a 24/7 resource deployed within the hub and spokes
2. Establish daily patient progression status updates and length-of-stay event management through team huddles
3. Deploy the hub-and-spoke model to ensure the execution of standard operating procedures and patient throughput milestones across all units and service lines
3. Implement hospital logistics software
Underneath the centralized care coordination model is a logistical control system. Like an air traffic control system coordinates all the planes in the air and on the ground, a hospital's "care traffic control system" coordinates every patient in every area of the hospital.
However, the software installation is the last, not the first, ingredient on the road to hospital operational efficiency. It provides the live analytics and logistical tools that ensure the hospital's system aim, centralized care coordination model, processes and success measures are aligned.
The logistics software, along with operational rounding, provided Mercy the framework to achieve dramatic patient throughput gains:
- Daily multidisciplinary team rounding, facilitated by clinical care coordinators, ensured that all patients were progressing effectively in accordance with the physicians' plan of care
- A real-time length of stay (LOS) management tool integrated with the hospital's ADT system tracked patients' real-time locations and approved days for concurrent LOS management
- The software continuously allowed the care team to see the estimated date and time of discharge from admission across every milestone of care
- Outpatient schedules, EHR orders and results were interfaced in real-time to the order logistics software
- Patient logistics enabled the hub clinical care coordinators to expedite bed assignments from all admission sources (direct, ED, perioperative, and transfers from other facilities)
Mercy's systemic transformation ensured that patients were where they needed to be for the right care at the right time from admission through discharge. The new approach and supporting software also helped Mercy transition from provider-focused priorities to patient-focused priorities and achieve the throughput and operational goals of the organization as a whole.
Patients, families and caregivers at Mercy Medical Center will be able to see a clear, updated patient itinerary at all times. As a result, Mercy's nurses know when to prepare patients for their scheduled services and procedures. Patients and their families know what services and procedures are to be completed on any given day so that they can ask the right questions and adequately prepare themselves. And those real-time itineraries automatically update as any scheduling changes are made.
The Results of Managing Patient Progression in Real Time from Admission to Discharge
Real-time patient throughput data gives hospital leaders and caregivers the information they need to round intentionally and effectively. Teams identify and address challenges, make adjustments quickly and measure improvements.
Within the first year of establishing these three ingredients for total hospital efficiency, Mercy Medical Center has recognized improvements in many key areas of patient care quality and efficiency:
- Reduced average patient length of stay by a full day, from 4.6 to 3.6 days
- Reduced observed length of stay-to-expected length of stay (O/E) ratio for targeted discharges from 1.34 to 1.06 over a nine-month period (The observed length of stay is the actual length of stay for the hospital's patients and the expected length of stay is CMS's geometric mean length of stay calculated for each DRG)
- Cut the number of patients who left the emergency room without being seen by more than half, driving the average down to 1.85 percent
- Reduced patient 30-day readmissions to 9.6 percent, a steady and continuing improvement in one of the key care quality measures that Medicare considers for care reimbursement
- Cut the time from a pending patient admission to assigning the patient a bed from 73 to 21 minutes, a 71 percent improvement
- Made a 50 percent improvement in inpatient satisfaction percentile ratings
- Won the Press Ganey 2013 Commitment to Excellence Award, reflecting the largest annual increase in employee engagement scores
- Reduced the door-to-door time for emergency room patients by an hour
- Reduced hospital-acquired pressure ulcers (HAPU) by more than half since February 2013
- Improved SKIP bundle from 94 percent to 97 percent
- Reduced length of stay of observation patients by 4.8 hours
The road to hospital operational efficiency isn't easy. It requires significant sacrifices and investments at every level of the hospital. However, the patients, physicians, and communities that hospitals serve deserve nothing less than a safe, satisfying, predictable, and reliable care environment.
Ben Sawyer is executive vice president of Care Logistics.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.