Pa­tient flow con­sult

To re­duce wait times, one hos­pi­tal hires out­side help, an­other chooses DIY

Modern Healthcare - - REGIONAL NEWS - By Steven Ross John­son

Four years ago, a visit to the emer­gency depart­ment at Mercy Med­i­cal Cen­ter for a non­life-threat­en­ing con­di­tion took more than three and a half hours from the time pa­tients walked through the door un­til the time they were treated and sent home.

“The pa­tient flow at that time was pretty dif­fi­cult—lots of grid­lock, in­pa­tient beds full and pa­tients held in the emer­gency room,” said Dan Moen, CEO of Sis­ters of Prov­i­dence Health Sys­tem, which owns the 343-bed safety net fa­cil­ity in Spring­field, Mass.

The is­sue of long ED waits came to a head at a chal­leng­ing time for Mercy. Mas­sachusetts’ 2006 health­care re­form law had in­creased de­mand for ser­vices, and the num­ber of Mercy’s ED vis­its spiked, reach­ing more than 75,000 vis­its a year by 2011. The in­creased pa­tient load led to longer wait times, re­sult­ing in 4% of pa­tients leav­ing the ED be­fore re­ceiv­ing treat­ment, com­pared with the na­tional av­er­age of 1%.

Moen said some Mercy de­part­ments launched ini­tia­tives to re­duce ED wait times, but it be­came clear a more com­pre­hen­sive ap­proach was needed. So in 2011, Moen hired Care Lo­gis­tics, an Al­pharetta, Ga.-based con­sult­ing firm that helps hos­pi­tals im­prove clin­i­cal op­er­a­tions and pa­tient flow. He chose the firm af­ter vis­it­ing Mercy St. Vin­cent Med­i­cal Cen­ter in Toledo, Ohio, where he ob­served the firm’s suc­cess in im­prov­ing co­or­di­na­tion be­tween hos­pi­tal de­part­ments to shorten ED wait times.

“About an hour and a half af­ter we got there,” Moen said, “we looked at each other and said, ‘We re­ally need to do this.’ ”

Mercy is one of a grow­ing num­ber of hos­pi­tals that have turned to health­care con­sult­ing firms for help to stream­line and im­prove their clin­i­cal op­er­a­tions. In­creased fi­nan­cial pres­sures as­so­ci­ated with de­clin­ing in­pa­tient vol­ume, rate pres­sure from in­sur­ers, and Medi­care per­for­mance-based re­wards and penal­ties have forced many health sys­tems to search for ways to im­prove qual­ity and re­duce costs. Mean­while, other sys­tems, such as Cook County Health and Hos­pi­tals Sys­tem in Chicago, have cho­sen to ad­dress pa­tient-flow is­sues on their own.

“We’re start­ing to see hos­pi­tals em­brace the use of data and ef­fi­cient pro­cesses much the same way other

in­dus­tries have done for years,” said Brian San­der­son, man­ag­ing prin­ci­pal for the health­care ser­vice group at Crowe Hor­wath, one of the na­tion’s largest health­care con­sul­tants.

Dr. John Flynn, co-direc­tor of the Osler Cen­ter for Clin­i­cal Ex­cel­lence at Johns Hop­kins Uni­ver­sity in Bal­ti­more, said hos­pi­tals have hired con­sul­tants to im­prove the ef­fi­ciency of their clin­i­cal ser­vices, in­clud­ing emer­gency and surgery de­part­ments and spe­cialty clin­ics. “There’s a tremen­dous push for de­liv­er­ing ser­vices, de­liv­er­ing them more ef­fi­ciently and driv­ing waste out of the process,” he said.

Costs for such ser­vices can range from tens of thou­sands of dol­lars for in­ter­ven­tions that last a few weeks, to sev­eral hun­dred thou­sand or mil­lions of dol­lars for more in-depth pro­cesses that can take as long as a cou­ple of years. Tom Brunelle, a re­gional vice pres­i­dent for Care Lo­gis­tics, said his firm’s con­sul­tants may con­tinue to work with a hos­pi­tal for sev­eral years af­ter the ini­tial process changes are im­ple­mented. The cost of th­ese con­sult­ing ser­vices may be a de­ter­rent for some health sys­tems, Flynn said.

The to­tal num­ber of health­care con­sult­ing firms has in­creased at a rate of about 1.2% an­nu­ally over the past five years for a cur­rent to­tal of more than 40,000 firms with about 80,000 em­ploy­ees, ac­cord­ing to a March re­port con­ducted by mar­ket re­search firm IBIS World. It is un­clear how many of those 40,000 health­care con­sult­ing firms en­gage in process and pa­tient flow con­sult­ing.

In­de­pen­dent spe­cialty con­sult­ing firms are be­ing ac­quired by larger, gen­eral con­sult­ing com­pa­nies to gain en­try into a mar­ket with prof­its ex­pected to grow at an av­er­age rate of 4.3% in 2015. To­tal rev­enue is pro­jected to grow by 5% a year to more than $14 bil­lion by 2020, ac­cord­ing to IBIS World.

De­spite the trend to­ward con­sol­i­da­tion, the con­sult­ing in­dus­try re­mains frag­mented. In 2015, the three largest firms ac­counted for a quar­ter of to­tal mar­ket share, with more than 90% of com­pa­nies com­posed of fewer than 10 work­ers.

In ad­di­tion to Crowe Hor­wath, other big play­ers in health­care con­sult­ing in­clude Deloitte Con­sult­ing, which holds the largest share of the mar­ket at 10.5%, and IMS Health, which is sec­ond with an 8.5% share.

Not sur­pris­ingly, hos­pi­tals and health sys­tems are key clients for those con­sul­tants, ac­count­ing for more than 38% of their busi­ness, with phar­ma­ceu­ti­cal com­pa­nies sec­ond at 19%. One of health­care con­sul­tants’ ma­jor ser­vices is “strate­gic man­age­ment,” which makes up more than 36% of their busi­ness.

Health­care con­sul­tants of­ten use qual­ity im­prove­ment and change-man­age­ment strate­gies drawn from Six Sigma and Lean. Th­ese qual­ity and ef­fi­ciency im­prove­ment meth­ods have been adopted by an in­creas­ing num­ber of health­care sys­tems over the past decade to boost pro­duc­tiv­ity and re­duce costs.

Mercy be­gan work­ing with Care Lo­gis­tics on its sys­temwide trans­for­ma­tion in 2012. It added 24 nurses to serve as clin­i­cal-care co­or­di­na­tors. They are on duty around the clock to su­per­vise the lo­gis­tics for each ad­mit­ted pa­tient through­out their stay. A cen­tral hub is set up on each floor, where length of stay and es­ti­mated dis­charge time is mon­i­tored and op­por­tu­ni­ties to re­duce wait times for tests and other ser­vices are iden­ti­fied.

Ben Sawyer, ex­ec­u­tive vice pres­i­dent of Care Lo­gis­tics, said the goal is to re­duce “white space”—the time dur­ing a pa­tient’s stay when no clin­i­cal ser­vices are be­ing pro­vided be­cause staff are wait­ing for pa­tient trans­port, lab tests, or for a bed to be­come avail­able. Re­duc­ing this dead time short­ens over­all length of stay, which in turn frees up beds for pa­tients be­ing ad­mit­ted from the ED, Sawyer said.

Moen said Mercy’s part­ner­ship with Care Lo­gis­tics has paid off by shav­ing an hour off the amount of time ED pa­tients spend be­ing seen, treated and dis­charged. Th­ese ef­forts also have re­duced the av­er­age length of stay for ad­mit­ted pa­tients by a day. Th­ese changes have in­creased the num­ber of pa­tients who re­port be­ing sat­is­fied with their ex­pe­ri­ence in the ED, from 50% to 86%, and have con­trib­uted to a rise in staff morale.

Like Mercy, many hos­pi­tals have fo­cused their stream­lin­ing ef­forts on the ED, which can gen­er­ate sub­stan­tial rev­enue if it is ef­fi­ciently op­er­ated. But if pa­tient flow is backed up and a sig­nif­i­cant per­cent­age of pa­tients leave with­out be­ing seen, rev­enue drops. Hos­pi­tals par­tic­u­larly strug­gle with how to quickly iden­tify pa­tients who don’t truly need emer­gency ser­vices and can be treated through ur­gent care or some other less-acute level of care.

“The idea of EDs be­ing un­pre­dictable is very false,” said San­dra Mad­den, se­nior direc­tor for con­sult­ing and man­age­ment ser­vices at the Ad­vi­sory Board Co. “If you re­ally look at your ED, you could pre­dict prob­a­bly 80% of the ac­tiv­ity that you’re nor­mally go­ing to see. When you know what you’re tak­ing

“About an hour and a half af­ter we got there, we looked at each other and said, ‘ We re­ally need to do this.’ ”

Dan Moen CEO Sis­ters of Prov­i­dence Health Sys­tem

care of, you can attack it and make your care more ef­fi­cient.”

Some hos­pi­tals and health sys­tems have im­ple­mented qual­ity-im­prove­ment and cost-re­duc­tion strate­gies on their own.

“We felt an in­ter­nal process was much more ef­fec­tive in mov­ing things through,” said Dr. Jeff Schaider, chair­man of the depart­ment of emer­gency medicine at the Cook County Health and Hos­pi­tals Sys­tem, the safety net health­care net­work for the Chicago area. Schaider said he and other sys­tem lead­ers im­ple­mented a pa­tient-flow strat­egy out of a be­lief that they had the data and other ca­pa­bil­i­ties to carry out a plan on their own.

The in-house process en­cour­aged staff to take greater own­er­ship of the process, said Peter Daniel, chief op­er­at­ing of­fi­cer for the Cook County sys­tem. “I think the team work­ing to­gether made a big dif­fer­ence to the com­mit­ment to im­prove on a lot of th­ese ac­tiv­i­ties,” he said.

The ED at the sys­tem’s largest acute­care fa­cil­ity, Stroger Hos­pi­tal, sees more than 110,000 pa­tients an­nu­ally. It has one of the long­est wait times of any fa­cil­ity in Illi­nois—an av­er­age of more than two hours for pa­tients with non-ur­gent con­di­tions, ac­cord­ing to data from the CMS. In 2013, the share of pa­tients who left the Stroger ED with­out be­ing seen was about 10%.

Two years ago, Stroger Hos­pi­tal lead­ers be­gan a ma­jor re­struc­tur­ing that called for a vir­tual elim­i­na­tion of the ED wait­ing area. In­stead, the hos­pi­tal be­gan the prac­tice of im­me­di­ate bed­ding—send­ing pa­tients di­rectly to an avail­able bed in the ED where they are triaged by a nurse and seen by a physi­cian. The hos­pi­tal also as­signed a physi­cian to quickly eval­u­ate more-ur­gent cases as well as to as­sess, treat and dis­charge pa­tients whose con­di­tions were not se­ri­ous. Ef­forts also were made to re­duce the time it took to get lab-test and di­ag­nos­tic-imag­ing re­sults, in­clud­ing the in­stal­la­tion of ad­di­tional imag­ing ma­chines.

Since mak­ing the changes, Schaider said the num­ber of pa­tients who leave with­out be­ing seen by a doc­tor dropped by 75% from 2013 to March 2015, and the time from an ED pa­tient’s ar­rival to dis­charge was re­duced by 35%. “It’s been a great boost from a staff and pa­tient per­spec­tive,” he said. “Since we’re re­ally the front door of the hos­pi­tal, we re­ally needed to show that the front door was a friendly, ef­fi­cient and open front door.”

Daniel said that he’s pleased with the re­sults so far but that his hos­pi­tal still has work to do to fur­ther re­duce ED wait times to be­come more com­pet­i­tive with other hos­pi­tals.

Flynn at Johns Hop­kins said some hos­pi­tals that have hired out­side help to solve pa­tient-flow is­sues have found that con­sul­tants tend to use a one-size-fits-all ap­proach, with­out first get­ting a solid un­der­stand­ing of the client fa­cil­ity’s unique cul­ture. Also, some con­sul­tants with­out ex­ten­sive health­care ex­pe­ri­ence may rec­om­mend cost­cut­ting strate­gies that hurt qual­ity of care, he added.

Moen said that whether a hos­pi­tal uses an out­side con­sul­tant or seeks to im­prove pa­tient flow on its own, “it’s not rocket science. It’s get­ting the med­i­cal staff and their col­leagues all en­gaged in the right way.”

Staff mem­bers at Mercy Med­i­cal Cen­ter dis­cuss el­e­ments posted on a Care Connect Unit Board. The boards are on dis­play in ev­ery in­pa­tient unit at Mercy.

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