Emergency Department Directors Academy – Phase II
Show Me the Money: Business
Model for Patient Flow
May 2011
5/9/2011
The Business Case for Flow
Thom Mayer, MD, FACEP, FAAP
Clinical Professor of Emergency Medicine
George Washington University School of Medicine
Goals
• Discuss emergency physician
compensation
• Discuss employees vs. independent
contractors
• Discuss methods of connecting work
performed to compensation
• Discuss how to maximize value
through flow
1
5/9/2011
The Mayer Rules
• Rule #1 Always do the right
g for the patient.
thing
• Rule #2 Always do the right
thing for the people who take
care of the patient.
• Rule #3 Rule #1 always takes
priority over Rule #2
What’s the Point?
• Take care of the patient
• Know the rules of documentation
and the business of medicine
• The Dollars will take care of
themselves
2
5/9/2011
The Many Faces of “Pay”
•
•
•
•
•
•
•
•
•
•
Patients per hour
Hours per week
Weekend cycles (every third)
Night shifts (1.4 X base salary)
Ease of dealing with attendings
RN’s (are there any?)
Boarders
Residents
PA’s, NP’s
Scribes
The Many Faces of Pay
• Vacation
• Trades
• Tickets punched-career
development
• Awards-Customer Service
• Perks
• Benefits-pre-tax
Benefits pre tax vs
vs. post
post-tax
tax
• The “buying power” of economies
of scale (spending 14% to buy 25%)
3
5/9/2011
There is some one Myth for every man, which, if
we but knew it, would make us understand all that
he did and thought.
How Do You Define Success?
Does your group know this?
7
4
5/9/2011
Show Me the Money!!!!!!!
Employee
•
•
•
•
•
•
•
•
Set hours
Set conditions
Set Comp
Benefits
Withholding
401K
Profit Sharing
Part of group
IC
•
•
•
•
•
•
•
Free Range Chicken
$/hour
No Benefits except MP Ins
No withholding
Accounting Cost
FICA Issue with IRS
Retirement $$$
5
5/9/2011
Employee vs. Independent Contractor
Employee
E
Employer
l
•
T Withheld
Tax
Withh ld
•
FICA/Medicare
½ Each
•
Benefits
Employer/Café
•
Pension
$14K + match
•
Deductions of
business exp
Relationship
Independent Contractor
•
1/4l b
1/4ly
by IC
•
IC pays all but writes off
•
IC driven (spouse issue)
•
IC paid to $44K
Employer paid
or >2% income
•
Schedule C limitations IRS
Part of the group
•
Free range chicken
10
Key Questions?
• How can the group best hold the physicians
comprising the group accountable to a
meaningful and collaboratively-generated set of
performance metrics? Nursing?
• What is a “good” doctor?
• What makes a “good” ED nurse?
• What is a “great”
g
doctor?
• What is a “great” ED nurse?
• What needs “fixing”?
• How is the “fixing” going to be done?
11
6
5/9/2011
2 EXTREMES IN PAY SYSTEMS
TEAM
Salary
Raise when good
Decrease when bad?!
INDIVIDUAL
FFS
Open books?
Increased coverage?
HYBRID
Salary
FFS Bonus
Billings
Per patient
Balanced Scorecard
2 Extremes in Pay Systems
TEAM
Straight salary/$per hr
INDIVIDUAL
Straight FFS
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5/9/2011
Fee for Service
•
•
•
An assortment of independently practicing MD’s usually (but
not always) with the same billing company
Ultimate open-book
Strengths
Moves the meat
Ultimate in performance-based
•
Recruitment (for those so inclined)
Weaknesses
No team basis
Frequent cross-purposes
Quality
Customer service
Is there accountability-who is in charge here?
How to account for administrative time, group growth,
etc?
Modified Fee-for-Service
•
•
•
•
•
•
•
Salary/FFS base
Si l billing
Single
billi
company
Stated plan, vision, mission
Pay per patient
Pay per month
yp
per quarter
q
Pay
Pay per year
8
5/9/2011
When are we, at long last, going to create
“Fee-for Service” Nursing?
16
Incentive and Pay System
• Pay people fairly and well-then try to
help them forget about money
• “If
If you want people to do a good job,
job
give them a good job to do.” Herztberg
• Stop fiddling-find a way to profit share
• Design the system with
Choice
Collaboration
Content
• Revisit the system-but not too often
(See #3)
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5/9/2011
Designing the Reward System
•
•
•
•
•
•
Ask the staff what they want!
Measure what matters
Align strategic incentives
Fair, objective, and credible
What you do matters…
Do the winners “win”
win in this system?
Bonus Systems – How Much?
•
What’s going to get their attention?
•
depends!
ds
Itt depe
•
In, general, 10-40%
•
10% is rarely enough
•
40% and you may be flirting with increased MD coverage
issues
•
•
Example $185,000 base salary
Bonus of $20-$80K
$5K-$20K
$5K
$20K per quarter
•
Range of $205,000-$265,000
10
5/9/2011
The Rule of Thirds
• One third of the ED Docs are highly
motivated and rewards will help
these folks
• One third are in the middle-the
reward will help, just not as much
as the top third
slugs-nothing s going
• One third are slugs-nothing’s
to move them (The Jack Welch
Rule???)
Rewarding by the Rule of Thirds
• Goal
• The reward system requires “filling the
minim m tank” to activate
minimum
acti ate the system
s stem
• The “tank” is defined both individually and
collectively (4S Dashboard-Science,
Service, Sustainability, Superior
Leadership)
• The
Th bottom
b tt
third’s
thi d’ tank
t k is
i unlikely
lik l to
t be
b
filled
• The middle third will do OK
• The top third will rake it in
11
5/9/2011
Difficult Issues
• Do we make more money or add more
coverage?
• Do we take on the new contract?
• Who assumes the risk (old and new)?
• How do we compensate for
administrative time?
• How do we develop new product lines?
(Pediatric EM, EMS, Sports Medicine,
etc))
• And, THE most difficult, disruptive issue
we face…
Perhaps the Ultimate Controversial Issue
• Should there be “compensation”
b
based
d on longevity?
l
it ?
• If so, how?
• How much?
• How long?
12
5/9/2011
Are You a Democratic Group?
Equity
•
•
•
•
•
•
•
•
•
Shares
Risk
Loans
Contract Risk
Leadership
PLI Tail
Contingent liability
“P fi ” distribution
“Profit”
di ib i
We few, we happy
few…
Parity
•
•
•
•
•
•
•
Voice
Governance
Direction
No inherent risk
Elected?
My opinion matters
Responsibility
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5/9/2011
How (and How Much)…
Should the ED Medical Director be paid?
26
How (and How Much)…
Should the ED Medical Director be paid?
• What do you want them
to do?
• Do they truly have
authority? power?
Influence?
• Or do they simply make
the schedule…
• 50% FT
• Funded by hospital (plus
clinical revenues if
needed)
• Worth 1.3-1.5 X Clinical
27
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5/9/2011
Patient Velocity and Revenue Velocity
•
A 35 year old female comes to the emergency department with
right lower quadrant pain. History and documentation are
precisely the same in all three scenarios.
scenarios
•
•
•
History and PE-call the surgeon to operate
Plus CBC, UA , Beta, KUB
Plus Sonogram and Abdominal CT
•
•
What are the E/M codes and payment?
Which is the most cost-effective ER Doc?
Form Follows Finance
•
IF YOU CREATE A SYSTEM WHERE THE FOCUS IS ON RVU's
GENERATED INSTEAD OF GREAT PATIENT CARE, YOU WILL FAIL
MISERABLY!!!!!!
•
YOU WILL BE MISERABLE !!!!!!!
•
IS THAT AN ED WHERE YOU WANT YOUR CHILD SEEN?
15
5/9/2011
As Always, A Little History is in Order
“Those who
cannott remember
b
the past are
condemned to
fulfill it.”
George Santayana
So How Does This go From RVU's to
Cash Money
•
•
•
•
Work RVU's X GPCI Plus
Practice RVU's X GPCI Plus
PLI RVU's X GPCI =
TOTAL RVU’s
•
•
•
•
TOTAL RVU's X Conversion Factor =
Medicare Allowable Payment
2011 CF= $33.9764
Is this an increase or decrease?
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5/9/2011
The Critical Impact of Downcoding
• 99284 to 99283 is a 47% reduction
• 99285 to
t 99284 is
i a 32% reduction
d ti
• 99291 to 99285 is a 29% reduction
• NOW, take that times 2.1 to 3.5 patients per
hour and you have Dirksen’s Law
• At 1,700 hours and $125 NCR, that’s between
$162,000 and $242,000 per year in charges
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5/9/2011
So, How Many RVU's per Hour Does an ED
Doc Generate?
• “It depends!”
• Patient Velocity (PV)
Billable Patients/Hours of coverage
• Revenue Velocity= PV X $Per Patient
Acuity
Coding
Do ncoding/Doc mentation
Downcoding/Documentation
Fee Schedule
Payer Mix
RVU's Per Hour Ranges
• Broad range of 4-10 RVU's per hour
• Heavily skewed to EDs in the 4.5-6.5 RVU's per
hour
• “A Team” members in flow-oriented systems
can hit 7-9 RVUs per hour consistently
• Can be seasonal
• Effected by pediatric, geriatric mix
• Nights are slower (or at least they used to be)
• The mix of E/M codes is critical to RVU's per
hour
• TC/CC high RVU's per patient but low PAVs
and RVs
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5/9/2011
Clinician Productivity
42
Effect of Acuity on RVU's Per Patient
•
•
•
•
•
•
•
15% Admissions
99281 0.5%
99282
5%
99283 45%
99284 28%
99285 18%
99291
3%
• Mean RVU/Pt = 2.38
• PV=2.0
• MC Comp=$161.84
•
•
•
•
•
•
•
31% Admits, Level I TC
99281
0.1%
99282
2%
99283
29%
99284
28%
99285
36%
99291
5%
• Mean RVU/Pt = 2.92
• PV=2.0
• MC Comp=$198.56
22
5/9/2011
Does This Mean the Higher RVU/Pt ED
Collects More $ Per Patient?
IT DEPENDS !
23
5/9/2011
Effect of Acuity on RVU's Per Patient
•
•
•
•
•
•
•
15% Admissions
99281 0.5%
99282
5%
99283 45%
99284 28%
99285 18%
99291
3%
• Mean RVU/Pt = 2.38
• PV=2.0
• MC Comp=$161.84
•
•
•
•
•
•
•
31% Admits, Level I TC
99281
0.1%
99282
2%
99283
29%
99284
28%
99285
36%
99291
5%
• Mean RVU/Pt = 2.92
• PV=2.0
• MC Comp=$198.56
Fundamental Conflict in ED Rewards
• Do you reward by teams or
i di id l ?
individuals?
• EM as the quintessential team sport
• Yet we have virtually
y no way
y of
rewarding teams in our specialty
24
5/9/2011
Features of an Ideal System
• Pay practices should reflect the
fundamental beliefs and values
• Pay practices should be public
• A tool, not a club
• This is what we value
Team goals
Individual performance
Creative and inventive ways to
compensate
Environment based on meaningful work,
trust, fun
Do Rewards work?
•
•
•
•
•
Define “work”
Temporary compliance
Moves the meat
Doesn’t address quality, service, innovation, etc
Bottom Line?
• THE CONSENSUS FROM
HUNDREDS OF MEDICAL
DIRECTORS IS THAT IT
MOTIVATES THE SELECT FEW
(SLIGHTLY) BUT REWARDS THE
RAINMAKERS (SOMETIMES
DRAMATICALLY SO)
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5/9/2011
Types of RVU Systems
• Pure RVU- No guarantees, no
exceptions, winner take all
• RVU Systems with Provisos
Nights
Pediatrics
CC Animals
Others
• RVU Systems with Base
Hourly/Salary Guarantees
Pure RVU's Generated
• Compensation = RVU's generated X $$/RVU
• Example
• ED Doc sees 2.2 patients per hour, with an RVU per
patient of 2.8 and a $22 per RVU rate
• 2.2 patients/hr X 2.8 RVU/pt X $22/RVU =
•
$135.52/hr
• ED Doc sees 1.7 pts/hr X 2.8 X $22/RVU=$104.72/hr
• This is a 30% difference in base compensation
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5/9/2011
Base Hourly Plus RVU Bonus
• Guarantee of $40/ hour
• RVU compensation of $15.50
$15 50 per RVU
• Compensation = 2.2 Pts/hr X 2.8 RVU's/Pt X
$15.50 / RVU =$95.48 + $40/ hour guarantee =
$135.48
• Compensation
Compensation=1.7
1.7 Pts/hr X 2.8 RVU's/Pt
RVU s/Pt X
$15.50/RVU=$73.78 + $40/hr = $113.78
Thus, a 20% difference in base compensation
High Guarantee Plus RVU Bonus
• $140 per hour guarantee plus
quarterly bonus based on % of
Total RVU's generated X Bonus $$$
Available
27
5/9/2011
Hourly Guarantee Plus Per Patient $$
• $115 per hour plus $16 per patient
bonus
• $115 per hour plus $16 per patient
bonus plus Quarterly bonus on %
RVU's generated
Hourly/Salary Plus RVU Quarterly
• $140 plus benefits
• Quarterly review of RVU's
generated
• Bonus paid on the basis of
profitability above targeted
expenses and margins
28
5/9/2011
How Much Variation Can You Expect?
• Compensation differences in a critical care
ED section can be as dramatic as 45-60 %
• Example:
• Dr A has a PAV of 1.77 X 2.92 RVU/PP X
$22/RVU = $113 per hour
• Dr B has a PAV of 2.89 X 2.92 RVU/PP X
$22/RVU =$185 per hour (65% difference)
• Pure Pediatric EPs are paid 20-30% less
than General EPs (With some dramatic
exceptions)
• Nights can result in 7-15% reductions in
RVU's generated (with wide variation)
What else should be rewarded?
• Service
• Science
• PG, PRC, etc scores
• Adherence to RM guides
• RVUs, $ generated, Flow
• Sustainability
• Superior Leadership
• 360 feedback, shift flow,
medical staff surveys
57
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5/9/2011
Creating a burning platform for change and improvement…
Aligning Incentives Around the 4S Scorecard
•Converting physician compensation models to a performance based model: a 6 – 9 month process required to get physicians to accept an “at
month process required to get physicians to accept an at risk
risk”// “bonus”
bonus structure. structure.
Science/Safety
Clinical Decisions
Adherence to Protocols
Patient Elopement
Charting Quality (Safety)
Service Quality
Downcodes
Patient Satisfaction
S
f
Sustainability
ALOS
Lab/X-ray TAT
PV
Superior Leadership
TBD
Internally and externally benchmarked
58
Metrics That Matter
• Patient Velocity (patients treated/hr)
• LOS (Discharged and Admitted patients)
• Essential Services Usage (CT, Lab, etc.)
• Productivity (RVU/hr)
• Documentation (E/M distribution)
• Patient Satisfaction
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5/9/2011
Patient Satisfaction – Individualized,
Trended and Internally Benchmarked
Courtesy
Listening
Informative
Informative Concerned about Pain
Open book test – consistent and repetitive coaching is key to sustaining superior results…
60
Ancillary Utilization – CTs/100 Patients
1. Increasing reliability by reducing variation
2. High of 36 per 100
3. Low of 19 per 100
4. Pushing group and individual performance to the Clinicians
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5/9/2011
Problems/Issues
•
•
•
•
•
•
•
Intra-group Competition
Si
Sign-outs
t
Pediatrics vs. General ED
Comfort zones of Docs
Too fast = Defendant
y Service
Too fast = Lousy
No team play = Dread to see the
schedule
Emergency Physician Compensation
• We are called to a great, but difficult
profession where the primary rewards are
are,
and always will be, personal, psychological,
and spiritual.
• That said, the financial rewards we receive
should be fair , reasonable,
reasonable designed to
produce great results and inclusive of the
vision, mission, and goals of the team.
32
5/9/2011
The Business Case for Flow
90,000 Visit ED
64
Kill Ya’s
•
•
•
•
•
•
•
•
•
•
•
I d
Inadequate
t nurses
Inadequate essential services
Long TAT, lab, imaging
EMR
Medical staff disengaged
Hospitalists vs. Dischargists
Unmotivated staff
Lack of accountability
No BABA
No Adopt A Boarder
Disconnect between the ED and
the rest of the hospital
Love ‘Ems
A
i t staffing
t ffi
• Appropriate
• Flex staffing
• Team-based
• Registration a part of the team
• Highly metrics-based
• Clear idea of success
• Clear TAT goals
• Service relationship
p with essential
services
• Effective use of MLPs and
Residents
• Spectra-link phones
• Scribes
65
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5/9/2011
ER Revenue Potential For 1 Hour Throughput
Reduction with Unmet Demand…
• 40,000 ED Visits X 1 Hr LOS reduction= 40,000 Hrs of ED
Capacity/ Year
• 2-3 Hours/Visit = 20,000-13,000 potential new visits
• 20,000 new visits X $100/Visit = $2,000,000 in new revenue
for the group
• 20,000 new visits x $500/Visit = $10,000,000 in new revenue
for the hospital
This potential revenue increase does not include the increase
in inpatient revenue at ($3,000-$7500 per admission)
66
66
Walkaways - LWBSs, LWOTs, AMAs
• Average $100 NCR MD income for every walkaway
• Average $300 in hospital income for every walkaway
• For a 50,000 visit ED= $50,000 in new MD revenue (no
increased overhead) for every 1% reduction in LWBS/LWBTs
• A 1% reduction in walkaways = $150,000 in new outpatient
hospital revenue
67
67
34
5/9/2011
The Business Case for Flow
• “Everyone deserves
an ED that works:
the patient,
the family,
the nurses,
And YOU!”
68
69
35
5/9/2011
The Dynamic Tension of Flow
WHY?
Why are we doing it this way?
Execution
WHY NOT?
Why not do it that way?
Agility
70
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5/9/2011
Flow
Service Transitions and Queues
• Adding Value
Increasing Benefits
Decreasing Burdens
• Decreasing Waste
72
All waste is burden
But not all burden is waste
• Oral Contrast in Abdominal
CTs
• 2nd Set of Cardiac Enzymes
in ACS
• Topical Anesthesia for facial
lacerations
• Total Body CT in Trauma
Patients
• Sequential Abdominal
Exams in acute abdominal
pain
• “Fill the bladder or I won’t do
the pelvic ultrasound.”
73
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5/9/2011
The front door and
your front end processes
drive flow
74
The Flow Cascade
•
•
•
•
•
•
Direct to Room
Ad
Advanced
d Triage/Rx
Ti
/R
Team Triage
Mid-level in Triage
UltraTrack
g
Results Waiting
Room
38
5/9/2011
Team Triage and Treatment-T3
Urgent Matters Grant-2002
• Addresses capacity constraints creatively by “moving
upstream” in the process in a dramatic fashion-forward
upstream
fashion forward
deployment of resources
• Doc, RN, Tech, Registrar in or near the triage area
• Requires “catching the ball” in the back
• Requires not just bodies, but fundamental change in
resources, processes, and philosophy
• Registration is a key stakeholder and must be involved
early
Getting it Right at the Front End of the ED
Service Operations and the Science Behind our Approach
• Measure patient demand by hour and design a system to handle it
• Commit to the right staffing mix—and the right staff
• Make sure your triage processes enhance flow, not form a
bottleneck
• Use a simple and reliable system to segment patient flow
• Design and fully optimize a Fast Track
• Establish a results waiting area
77
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5/9/2011
Triage is a process, not a place
Don’t call it “Triage…”
Call it what it is…
“Welcome”
Intake”
“Intake
“Segment”
78
Script
• “We knew you
were coming
i in
i
today--we just
today
didn’t know your
name!”
40
5/9/2011
“Name, Rank, and Serial Number…”
•
•
•
•
•
•
Name
Limited chief complaint
Vital signs
Pain score
“Sick or not sick”
Resources Needed?
80
Patient Segmentation
by
Acuity
ESI 5
ESI
5‐Level
Level Triage Triage
System:
• Easy
• Highly Reliable
• Allows for quick patient segmentation
ESI 5-Level Triage system
© ESI Triage Research Team, 2004
81
41
5/9/2011
Segment Flow
Triage
Brief RN Assessment:
ESI Evaluation / Evaluation of Acuity
Low Acuity
Pathway
ESI Levels 5, 4,
+ some 3s
High Acuity
Pathway
ESI Levels 1 + 2
Moderate Acuity
Pathway
Most ESI Level 3s
82
Measure and Act on
Demand Capacity Issues
•
Historical staffing patterns have been
sustained at NCH since BP began
staffing in June 2006
Demand vs. Capacity
Main ED
9
•
Volume decline with economy
–
Anticipated given a major multi-year
facility renovation process and
economy
8
7
Staffing
Mismatch
6
5
4
•
With the decline in volume, our
schedule no longer matched our
demand for clinicians
3
2
1
0
•
Physician earnings have declined
slightly since the introduction of a
productivity-based compensation
system in 2009
Modeled Demand
Average Demand
Current
83
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5/9/2011
NCH Staffing Optimization
Approach
Demand vs. Proposed Capacity
Main ED - Heavy Days
•
6.0
Working closely with the NCH
leadership team, we refined the
schedule with several clear g
goals
–
–
5.0
4.0
–
3.0
2.0
1.0
•
Schedule development and final
agreement on solution is an iterative
process, including multiple modeling
sessions with the leadership
p team
and input from clinicians
•
NCH leadership team owns final
outcome and is incentivized on its
success
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
0.0
Average Demand
Modeled Demand
Match capacity to demand
Differentiate between heavy and light
days
Maximize use of less expensive staff
resources where appropriate
Proposed
84
Sunday and Monday – Peak Days
Jan – Aug ’09 Arrival Data
85
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5/9/2011
Hospital-Wide Patient Flow
An Administrative System
Admissions
A Bed
Management
Process
Real Time
Demand/Capacity
System
Transfers
Discharges
An Early Warning
and Response
System
Forecasting and Planning
86
Real-Time Demand Capacity Management
The Joint Commission Journal on Quality and Patient Safety
May 2011 Volume 37 Number 5
87
44
5/9/2011
What we would like to see…
Rapid Admission Process™
Admission
Triage
Get the patient and the doctor together
as quickly and efficiently as possible
89
45
5/9/2011
Streamlined Front End ED Patient Flow
Northwest Community Hospital
ATU Performance Outcomes
Metrics Pt. Satisfaction Likelihood of Recommending ATU Overall ATU Goals >90th Percentile >90th Percentile Doctors Std ATU >90th Percentile LWBS <1% Length of Stay <100 minutes October
November
December
January
February
March
51
83
99
84
99
26
99 69
94
90
93
99
39
96 April 51
94
85
90
99
95
96 0.3%
119
0.5%
119
0.3%
110
0.2%
104
0%
117
0%
99
0.3% 113 *PG 40k or More Database 46
5/9/2011
Fast Track is a verb, not a noun
92
We “Fast Track” Lots of Sick Puppies
•
•
•
•
•
•
Major trauma
STEMIs
Code Vascular
Code Stroke
Code Blue
Any EBM pathway?
93
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5/9/2011
Let’s “Fast Track” Everyone We Can
• EBM and EBL are inextricably linked
• Both
B th require
i courage, consensus
consensus--building
b ildi
and a healthy dose of impatience
• You will never satisfy patients or staff if you
tolerate B Team processes
• Do the processes add value or contribute
waste?
t ?
• Segmenting flow adds value
Keep your vertical patients vertical
and in motion
95
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5/9/2011
Optimizing ED Treatment
for ESI 5s, 4s, and Select 3s
Laboratory
Supplies
Supplies
Room 12
Office
Office
Clean Holding
Room 9
Room 10
Room 11
Z
Zone 1
1
Zone 2
Zone 3
Zone 4
Triage area
EMS Room
Room 1
Room 14
Hall Space
Room 15
Room 2
ED Core
CH 1
CH 2
CH 3
CH 4
Trauma Entrance
Room 8
Office
Room 7
Room 6
Room 5
Room 4
Trauma
Room 3
Trauma
HealthPlex Performance Outcomes
Courtemarche #1 FSED
Metrics
Q2 2009
Q3 2009
Q4 2009
Q1 2010
83
86.4
89.8
87.6
Nurses Understanding and Caring
86.5
87.4
90.8
92.2
Overall Teamwork Between Doctors, Nurses and Staff
85.9
83.6
89.1
88.6
Patient Satisfaction*
Overall Quality of Care
LWBS
0.9
0.6
0.5
0.3
Length of Stay
Length of Stay
149
141
135
131
Patient Volume
10042
9446
9670
8732
*PRC
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5/9/2011
Patients who need few or no resources
should not routinely wait
behind those patients who need multiple
resourcesNo matter how heavy the ED patient
volume…
98
The MVP of Your Hospital?
50
5/9/2011
Do All Patients Need Beds?
The answer is “No…”
The challenge and opportunity is defining
and identifying which patients do and do
not need beds
beds…and
and if they do need a bed
bed,
what for and for how long…
long
For horizontal patients, real estate matters
For vertical patients, speed matters
101
51
5/9/2011
We want to be fast at fast things
and slow at slow things
102
Fast or Slow?
•
•
•
•
•
•
•
18 y/o lacrosse player with inversion injury
50 y/o with abdominal pain
pain, nausea
nausea, vomiting
50 y/o with hx of renal stones and 10/10 pain
50 y/o with hx ASCVD and intense abdominal pain
17 y/o with groin pain
2 y/o with 3 cm facial laceration
20 y/o with 10 cm laceration
• Segment
• Value= Benefit/Burden Ratio
103
52
5/9/2011
Flow occurs when doctors do “doctor stuff”
and nurses do “ nurse stuff”
104
Doing is Documenting
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5/9/2011
InQuickER
•
•
•
•
•
Ultimate FFS as a waiter
Table turns are key
Who puts the table back in
service
Technology to support this
Developed by…a waitress!
•
•
•
•
•
•
Make an appointment for care at
a convenient time for you
Ability to pre-register for the
acuity level for your
illness/injury
p
Fee-based relationship
Barriers to entry are low, but
few people will develop their
own
“For you, the wait time is zero!”
More to come
Flow and the Psychology of Waiting
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5/9/2011
Putting the Psychology of Waiting to Work
•
Unoccupied time feels longer than occupied
time
–
–
–
–
•
Pre--process waits feel longer than in
Pre
in--process
waits
–
–
–
–
•
Immediate bedding
No triage
AT/AI (Advanced Treatment/ Advanced
Initiatives)
Team Triage
–
Making the Customer Service Dx and Rx
Address the obvious-pre- thought out and
sincerely deployed scripts
Patient and Leadership
p Rounding
g
Uncertain waits are longer than known, finite
waits
–
–
–
–
–
Previews of what to expect
Expectation Creation
Green-Yellow-Red grading and information
system
Traumas, CPRs-Informed delays
Patient and Leadership Rounding
Unexplained waits are longer than explained
waits
–
–
–
–
•
•
Announce Codes
Fast Track Criteria known and transparent
The more valuable the service, the longer the
customer will wait
–
•
In-process preview and review
Family and friends
Address the obvious-pre- thought out and
sincerely deployed scripts
Patient and Leadership Rounding
Unfair waits are longer than equitable waits
–
–
Anxiety makes waits seem longer
–
–
•
•
TVs, magazines, health care material
Company-friends and family
ROS forms, kiosk, pre-work
Frequent” touches”
The Value Equation -Maximize benefits for the
patient and significant others + Eliminate
burdens for the patient and significant others
Solo waits feel longer than group waits
–
–
–
–
Visitor Policy-The Deputy Sheriff takes a
furlough
g
Managing the family’s expectations
It’s OK to leave for awhile
On-stage/Offstage
108
Finding Flow Requires…
• Taking people out of their
comfort
f t zones
• Asking “Why?” and “Why
Not?” Incessantly
• Getting
g them with you
y
on the
takeoff
• Creating hope…
109
55
5/9/2011
References
110
56