Palomar Health is the largest public health care district in California by area. The system includes three hospitals, two hospital-based emergency departments (EDs) and a stand-by ED; and CEP America currently staffs Palomar Health's EDs and inpatient departments.
As the Palomar Health system grew, patient flow across facilities became increasingly complex, and ED throughput and internal transfer times rose. To tackle the problem, Palomar Health and CEP America teamed up to create a centralized patient placement system capable of coordinating care across facilities.
Though this work is still ongoing, Palomar Health has already seen significant throughput improvements, and admission rates are up across the system.
The following is based on a poster presented at CEP America's 2014 annual conference.
Prior to 2013, bed placement at Palomar Health was handled by individual house supervisors at each hospital. This decentralized approach made it difficult for the system to meet core measures. By 2013, Palomar Health’s turnaround time to admission (TAT-A) was above the national average at about 400 minutes. Lack of care coordination also increased both the number of internal transfers and time needed to move patients to the appropriate care setting.
Administrators and providers were concerned. Evidence shows that patients who stay in the ED for an extended amount of time have increased risk for mortality and extended length of stay (LOS)
in the hospital. It was also clear that Palomar Health's admissions process was difficult for both referring physicians and patients to navigate. Sometimes patients who should have been admitted directly to the hospital got confused and ended up in the ED, increasing their stress and exacerbating ED throughput issues.
Aligning for Better Care
In 2013, Palomar Health identified "improved care coordination and throughput" as a systemwide strategic initiative and organizational goal. The system decided to focus on the following areas:
- Improve Care Coordination: Develop a delivery model that supports care coordination and transitions across the continuum, with emphasis on chronic disease management, illness prevention and patient involvement.
- Improve Satisfaction and Throughput: Create a positive experience for all key stakeholders by improving clinical and business throughput and efficiency through all transitions of care.
With the assistance of a CEP America practice management consultant, Palomar Health formed a multidisciplinary Patient Flow Steering Committee to improve throughput across the system. Membership included representatives from med-surg, ICU, ED, telemetry, registration and case management.
Centralized Placement Program
In 2014, the Patient Flow Steering Committee's TAT-A subgroup focused on creating a centralized bed placement system that would work as a single entry point for all admissions and transfers:
By centralizing bed placement, the group hoped to:
- Improve throughput and decrease ED LOS
- Decrease the number of patients that leave the ED without being treated
- Improve customer satisfaction
- Improve the overall quality of care
To facilitate the transition to centralized bed placement, the TAT-A subgroup implemented a number of new initiatives:
- Care concern line
- TAT-A log
- Daily throughput huddles
- Throughput scorecard and enterprise dashboard
- Redesign of discharge timeliness initiative
- Redesign teletracking workflows
- Bed-ahead identification
- Removal of nursing blackout times
- Housekeeping/transport turnover and staffing analysis
- Historical throughput analysis tool
To help providers and nurses facilitate admissions, the committee also created a stepwise workflow utilizing the ED tracking, hospital-wide teletracking and EHR systems.
In addition, Unit-Based Med Management (another subgroup of the Patient Flow committee) focused on two tasks:
- Restructuring the bed huddle process to include the use of teletracking, ensure consistency, increase awareness of discharge delays, discuss LOS issues and encourage staffing conversations.
- Redefining the written patient placement criteria, making it a more clear and precise document.
New Job Descriptions
To coordinate centralized bed placement, and with the full support of the Palomar Health administration, the committee restructured the house supervisor role to create two new positions:
Patient Placement Supervisor
Patient Placement Representative
- Works in the centralized placement office to ensure seamless flow of patients through the hospital’s systems and operations.
- Coordinates all services to provide a patient-centric approach to care.
- Responsible for monitoring and meeting established performance metrics throughout the hospital-wide system of care.
- Processes patient placement requests for all inpatient transfers and all points of entry into the hospitals.
- Receives requests for incoming patients and works with the accepting physician and nursing unit staff to identify the best available placement for each patient using the electronic bed board.
- Gathers all information pertinent to the placement decision.
- Reviews incoming admissions for appropriateness, utilizing documented criteria to determine whether the patient meets requirement for inpatient or observation status.
While work continues on the centralized placement process, Palomar Health achieved the following gains within six months:
- Reduction of 120 minutes for TAT-A
- Reduction of 25 minutes for turnaround time to discharge (TAT-D)
- Widespread integration through Patient Flow Initiative
- Participation from every contracted physician group
The hospital marketed its new, streamlined admissions process to primary care physicians, resulting in a marked increase in the number of direct admissions.
Going forward, the Patient Flow Initiative will continue to enhance throughput across the Palomar Health system by focusing on:
- Integration of nurse staffing program
- Discharge timeliness scorecard
- Full transfer center implementation
- Integrated callback program
- Case review management workflow
- Transitions of care
Since this poster was presented in Fall 2014, Palomar Health has continued its work around patient flow with excellent results. ED TAT-A has now declined to about 275 minutes across the system. What's more, these improvements were sustained when ED volumes unexpectedly surged last winter.
The new centralized placement system has been well received by the community. Physician referrals are up, and admitted patients no longer turn up in the ED by mistake. This year, admissions from the ED hit an all-time high of 37 percent thanks to the new capacity created by the centralized placement program.
[Image credit: "Egg (safer kumquat replacement) Photography"
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