ED-HOSPITALIST SYNERGY

Presented by:

PRESENTING:

ED‐HOSPITALIST SYNERGY

Robert Moskowitz, MD MBAMedical Director of Emergency Dept

Mercy HospitalMiami, FL

Sareda Nur, MDMedical Director of Hospitalist Services

Southern Hills Medical CenterNashville, TN

OBJECTIVES• Examine common inefficiencies in care/flow during a patient's

hospitalization

• Outline the synergistic effects of aligned incentives between ED physicians and hospitalists

• Describe a patient‐centric model that encompasses a patient's entire hospitalization

• Offer our personal experiences and outcomes in assessing and integrating the Door‐to‐Door model

• Offer a template for hospitals looking to increase efficiencies that are sustainable

ED ‐ HOSPITALIST SYNERGY1. Initial State

2. Roadmap for Success

3. Future State

ED ‘SILO’‐ISMS1. Sole focus on getting the patient ‘door to floor’ or ‘out the door’

2. Define efforts in minutes

3. Quick handoffs/soft sells

4. Minimizing testing

5. ‘Faceless Voice’ syndrome

6. Ignorant of inpatient resources

7. Reactive feedback to patient care

HOSPITALIST ‘SILO’‐ISMS1. Defining efforts in days

2. ‘Ribbon‐on‐the‐box’ syndrome

3. Reanalyze ED workups

4. Faceless Voice syndrome

5. Ignorant of ED resources

6. Floor to Door focus

7. Dealing with Consultants

ADMINISTRATION ‘SILO’‐ISMS1. Departmental meeting structures

2. Information sharing between departments

3. ‘Stick to your Stethoscope’ syndrome

4. Visitation fly‐bys

5. Departmental budgeting

6. Staffing

SYNERGISTIC FLOW MODEL

Walk‐ins

Transfers

Direct AdmitsPost‐Op Cases

EMS

DOOR TO DOOR

Transfers

• SNFs• ALFs• Home• Family Members• Group Homes• Shelters• Rehabilitation• Psych/Detox

WHAT ARE WE MISSING?Better Understanding of:

• Terms

• Utilization

• Resources

• Comparable

• Successes/Failures

Learning to:

• Allocate roles

• Share information

• Reassess efforts

• Educate/Implement

• Trust

ROAD MAP FOR SUCCESS: LARGE SCALE LEAN PROJECT

Flow Improvement in the ED: Streamline the Inflow and Outflow

• These can occur in parallel or overlap in the details, but they both need to occur

• Requires active involvement of Hospital Administration

Flow Improvement House‐Wide

GOALS OF A PATIENT‐CENTRIC SYSTEM

1. Maximizing efficiency and eliminating waste in the staffs’ routines

2. Efficient workups and dispositions

3. Streamlining admission process from the ED

4. Improving discharge processes from the floor

5. Improving transfers within the hospital

6. Improving bed management systems

7. Reassessments/feedback systems

8. Accountability

9. Tracking data

SOUTHERN HILLS MEDICAL CENTER• Annual ED Volume 36,000K as of 5/2011

• 18 Bed ED (12 main, 6 bed Fast Track)

• 132 Beds Hospital

• 10% Admission Rate

• Prior to 2011 ‐ Separate ED provider and Hospitalist Groups

• 5/2011 ED Contract changeover

• 11/2011 Hospitalist Contract changeover

SOUTHERN HILLS MEDICAL CENTER• At outset ED struggled with:

• Throughput times

• LPT/LPMSE rates

• (lower end of division)

• Patient satisfaction

• At outset Inpatient Medicine struggled with:

• Permanent/Committed staff

• Relationship between ED and Med Staff

• Opportunity/Environment right for change

SOUTHERN HILLS TIME LINEED LEAN event ‐ Summer 2011

• 3 and 6 Month Goals

Hospital LEAN event ‐ February 2012

• 3, 6 and 9 Month Goals

Incremental improvements in

• All throughput metrics

• Increased patient satisfaction scores

• LPT/LPMSE rate decrease (front runner in division)

• Improved hospital culture and interdepartmental relations

• Increased ED and EMS volume

ASSESSMENT OF PROCESSES AND PERSONNEL• ED Director & Hospitalist Director meetings

• Separate provider meetings

• Combined provider meetings

• Provider committee involvement

• Utilization meetings

• LEAN Events ‐ with all staff

• Multidisciplinary Rounds

• Flow Meetings ‐

• Separate department meetings with ancillary staff

• Step‐down fashion after LEAN events….but they NEVER end

FUTURE STATERedefine the culture at the hospital by implementing a process that is:

• SUSTAINABLE

• PATIENT‐CENTRIC

• ACCOUNTABLE

• RE‐ASSESSABLE

ROADMAP FOR SUCCESS

• Not an overnight process• Constant communication and reevaluation• Continuous education• Intestinal fortitude

QUESTIONS/DISCUSSIONQUESTIONS/DISCUSSION

ED-HOSPITALIST SYNERGY

Health & Medicine

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