Patient Care Delivery

HEALTHCARE BUSINESS INSIGHTS PATIENT CARE DELIVERY

Cost & Quality Academy Journal January 2017

Expediting Oncology Care Through Nurse Navigation to Alleviate Patient Challenges Many oncology and cancer programs can be fragmented due to the length of time Greenville Health System South Carolina between patients’ appointments and the number of healthcare professionals they • Number of Licensed Beds: 1,662 need to see before a consensus can be • Hospital Discharges: 51,895 reached about treatment plans. This may cause patients to become anxious and • Number of Cancer Institute Offces: 8 frustrated with their overall experience with oncology care. To help alleviate these navigators’ role in bridging gaps in oncology calm those fears. The nurse navigator is negative care experiences, some health care, The Academy spoke with Julia Yates, critical for a successful visit for the patient systems have expedited the cancer treat- MSN, RN, OCN, Clinical Nurse Manager for and families because they’re procuring ment process with nurse navigators. the multidisciplinary clinic and oncology records, including pathology and imaging Greenville Health System (GHS) Cancer support services, which include nurse navi- studies, and being available to the patient Institute—which has the largest cancer gation services. for education and support.” program in South Carolina and provides Identifying Patient Needs The initial workup for a suspected malig- services to five counties in the state— nancy can involve numerous exams and implemented the use of nurse navigators to “The patient may become very anxious, tests. Waiting for a final diagnosis plan of act as liaisons between patients and treat- especially when they are newly diagnosed care can be a very high-anxiety time for ment providers. Moreover, GHS employs and awaiting a treatment plan,” Yates says. patients, especially with the process some- a multidisciplinary clinic to address the “So seeing patients at a multidisciplinary times extending over weeks. The oncology individual needs of patients with differ- clinic, with two to three physician special- ent diagnoses. To learn more about nurse ists at once, is extremely efficient and can SEE ONCOLOGY ON PAGE 2

Improving Departmental Efciency Through Value Stream Analysis and Other Lean Methodologies Safe and efficient delivery of care in the such as redundancies in physical actions, “Our Senior Vice President at the time Lean surgical department is an ongoing ambi- disorganized unit navigation, and a lack was initiated said our numbers were down, tion for many hospitals and healthcare sys- of comprehension of staff responsibilities we were losing patients, and we needed to tems. However, operational inefficiencies undermine the timeliness and quality of look at our processes,” Dr. McNelis says. surgical care. As a result, it is important for “So we took that message and identified surgery as one of the areas that needed a Turnaround Time in the Orthopedic Unit organizations to identify operational inef- at Jacobi Medical Center (in Minutes) ficiencies and develop targeted and sus- value stream analysis.” tainable changes to achieve high-quality 32.3 surgical care. Identifying Improvement Needs Jacobi Medical Center of NYC Health + Value stream analysis is a Lean method- Hospitals—a 457-bed trauma and tertiary ology that identifies and assesses steps 18.4 care center in the Bronx, New York—has needed to bring a project from its current utilized Lean methods to improve effi- state to the ideal state. Jacobi hired exter- ciency in its surgical department. In par- nal Lean assistance personnel who were ticular, Jacobi’s value stream analyses heavily involved in the initial assessment identified key areas for improvement and and development of its perioperative value Pre- Post- initiated focused changes. To learn more streams before implementing the neces- Implementation Implementation sary efficiency changes on its own. The sur- about the efforts of the facility and its tar- By utilizing Lean methods to improve inef- gery department framed this value stream fciencies in surgical care processes, Jacobi geted surgical department improvements, initiative around the current state of its Medical Center reduced patient turnaround The Academy spoke with Dr. John McNelis, time in its orthopedic unit by nearly 50%. Chair of the Department of Surgery. SEE VALUE STREAM ON PAGE 4 2 COPYRIGHT © DECISION RESOURCES, INC. ALL RIGHTS RESERVED. Dur needs. individual their on ing focus and education, support, advanced f patientsthatand stress the of someviate alle to aims Institute Cancer GHS at team FROM DELIVERY CARE PATIENT p availablethe toremains and visit this out through available is navigator nurse The conference. collaborative this plan following proposed the of practitioner with each meets then patient The plan proposal. treatment a develop and options, pathologist treatment meet discuss to records, review and radiologist, nurse navigator, oncologist, radiation oncologist, of group a s MDC, the of format orative v of weeks several taken have may viously pre what visit single a in accomplish to patient a allows MDC The (MDC). Center Multidisciplinary its through treatment patients its for b expe process care also the has dited Institute Cancer GHS needs. healthcare n adapt and transform help can cussions dis continual These developments. gram pro new to lead may which issues, these address to ideas and challenges,barriers, an o present visits These resources. able vations regarding patient needs and avail obser their discuss to visits one-on-one for manager their with meet navigators ml mmes xeine y providing by experience members amily pecialists including a surgeon, medical medical surgeon, a including pecialists stn dfeet ie. ne te collab the Under sites. different isiting y offering a unique approach to cancer cancer to approach unique a offering y avigation to meet patients’ specific specific patients’ meet to avigation pportunity for staff members to discuss discuss to members staff for pportunity atient and the patient’s family through through family patient’s the and atient impact and improve overall efciency. positive havecould considerable education for roles standardizing education, patient of involved type when it toprovider comes on the dependent With diferences distinct Practitioner Provided to Patient (By Provider Type) Provider (By to Patient Provided % of Visits in Outpatient Department Department Outpatient in Visits % of Physician Physician Physician Assistant n mnhy edrhp rounds, leadership monthly ing in Which Health Education Was Was Education Health Which in Nurse Nurse ONCOLOGY Source: Ritsema TS et al. (2014)

ON PAGEON 1 20.2% 28.6% 31.0% ------and survivorship. and recovery, treatment, of course entire the is o te ains n fmle. The families. and p patients the for kits educational of r creation the and depart ment oncology the within education for responsible also are navigators Nurse w appoint expect to what and to bring, to what ments, get to how know they sure the nurse navigators patientscontact to make Additionally, oncologist. their with visit ﬁrst patient’s the to prior ready and f collected information the of All trials. cal clini for eligibility and reports, genetics, patient prepare results, test type, cancer the with records and track navigators nurse the case responsibilities, and nursingmanagement dual their of part As trending upward. day for areas an additional sites or opening multiple clinic at staff same the using as provide insight into utilization needs, such Cancer Institute and assessed for trends to T physicians. by set is which clinic, plinary n gators are not limited and are based on the navi these for Caseloads concerns. other and changes, lifestyle medication, about questions with night, or day time, any at process. Patients may call nurse navigators treatment the throughout caregivers and a counsel families.remainTheypatientsand for ors and educators, coordinators, care clinicians, as GHS serve Institute Cancer the at navigators nurse Oncology Guiding Patient Care or a patient’s records are documented documented are records patient’s a or sucs sc a bolt ad tool and booklets as such esources, albe n i cnat ih h patient the with contact in and vailable ee ubr ae rce b te GHS the by tracked are numbers hese umber of patients seen in the multidisci the in seen patients of umber atients are given booklets that reiterate that booklets given are atients hen they to come the clinic. ensure that patients receive appropriate care. may indicate the need for case management to displaying noncompliance for radiation therapy treatment noncompliance, one in fve patients With poor patient outcomes associated with % of Patients Noncompliant with with Noncompliant % Patients of Radiation Therapy Treatment Therapy Radiation Source: Ohri N et al. (2016) 22% ------r community additional with patients vide l videforareinability paytoforservices or pro navigators that assistance agement Twomainareas nonclinical of caseman barriers. their external overcoming and in families their them through assist navigators patients care, guide further To patient’s diagnosis. cancer a after members family assist to toolkit caregiver a developed also has Institute Cancer GHS The home. return they when support additional with them provide to program the to speciﬁc instructions and preoperative and postoperative education h MC t h GS acr Institute Cancer GHS the at MDC The Providing Reliable Care trans portation for and appointments. services, payment care in-home treatment plans, billing, with them they survive.” while thrive to all them enabling by patients for goal the Yates is “Empowerment caregiver,” says. and patient the empowering both on consistently focus “We care. oncology s tems can experience an increase in patient patients,toport hospitals healthandsys supsustaining andeducation, diagnostic i ableinsight. providingBy nurse navigators Health GreenvilleS of practices the ogy, imple ment a nurse for navigation program oncol to looking organizations other For care experience. oncology overall their ease and patients opinion second these for records outside v system its of outside facilities with rates t anddiagnosis cancer theirregarding ions opin second seek and to referred are ters healthcare cen hospitals and other from Due patients to of its the program, success and suggestions guide our next steps.” andvalued,” Yates says. “Patient comments prepared, understood, heard, felt patient “Itisimportant toknow whether ornot the an increase in patient satisfaction. medicaldisciplines onevisit,in leading to r patient cancer each appointments of num ber the consolidated and reduced has c o spot t oe Nvgtr pro Navigators home. at support of ack mlil dsilns fclttn better facilitating disciplines, multiple n sucs n srie otcs o assist to contacts service and esources etet GS acr nttt collabo Institute Cancer GHS reatment. multiplesee toableequires.Patients are atisfactionimprovedand management of ia its electronic health record to procure to recordelectronichealth its ia ystem Cancer Institute can provide valu provide can Institute Cancer ystem

2011 136.0 Source: CDC (2014) CDC Source: 2010 129.8 Emergency Department (in Millions) Numberof Patients Presenting tothe ose by nearly seven million from to 2010 PATIENT CARE DELIVERY The number of patients presenting to emer to presenting patients of number The gency departments in the United States r highlighting2011, the need for efective transfers. patient enter enter may act as a prime example. By atients and is currently evaluating the an an arise. Each month, Harris Health’s ice presidents ice and presidents chiefs of staff at both time time we determine the correct service, it took two hours instead of one hour.” To help address those health challenges, the system created lines for trauma, stroke, and heart transfer attack guide p need for additional hospital has Health Harris guidelines. year, past the over Thus, successfully transferred 1,200 patients approximatelybetween improve to looking its systems hospitals.health other For strat the transfers, patient intrasystem their egies of Harris Health System’s Transfer C using a specially Transfer other Center, hospitals staffed, may also always-open coordination. care improved experience Transport Transport Committee meets to cases discuss or of and process quality any issues concerns regarding transfers intrahospital con committee This arisen. have may that sistsof the chief medical officer, vice presi administrative and affairs, medical of dent v Hospital. Johnson B. Lyndon and Taub Ben “Issues such as any potential delays and are examined,” transfer of appropriateness McMurray-Horton says. “For maybe the example, transferring hospital requested initially the wrong service, so by the to to and from external within organizations span. 30-day that With a high volume of ing patients locations, chang some unique c challenges ------emorandum of Transfer form for a par cMurray-Horton says. “Those are the two two the are “Those says. cMurray-Horton edical edical care while mobile. An electronic arris arris Health hospitals. In addition, the eds and coordinating direct patient admis patient direct coordinating and eds lso to ensure clinical information is read taffing, taffing, and appropriate specialists and ransfer, and mode of ransfer, be transport—must n n the event that both Harris Health sites nclude inpatient hospital units, the ED, and and ED, the units, hospital inpatient nclude Ben Ben Taub Hospital facilitates mately approxi 100 patient H transfers between transfers 700 of upward coordinates center completed completed by external facilities to ensure guidelines. EMTALA with compliance “If the medical staff feels a patient needs to not be capacity and transferred, there’s or we at capability will facility, either look to external hospitals,” McMurray-Hortonexplains. “The overall main focus is patient.” the of needs the clinical Transportation and Volume Managing Every month, the Transfer Center inside lance lance in order to remain under necessary m healthrecordutilizedstreamline is to com and hospitals system between munication a ily accessible upon arrival. I are unable to patient accept transfer, the Transfer Center staff an intrahospital will contact external ties healthcare to potentially care facili for that patient. A M ity ity and at capability the receiving facility,” M mainpieces thatmake thisprocess work— hospital our from information capacity the supervisors as well as the capability from our medical team.” Center Transfer the met, are criteria both If team contacts Harristransportation department that manages Health System’sEMS services to transportation to facilitate the appropriate receiving hospital. an via ambu transported are All patients procedural areas such as receiv the the If room. operating the or catheteriza lab tion ing hospital has beds, available adequate s care patient’s particular a meet to providers talk from both locations physicians needs, status patient’s the review to phone the over information. pertinent other and capac have we that sure make to have “We b sions to the care appropriate areas which i tion tion such as reason patient condition, for t ticular ticular patient—which includes informa ------mergency mergency Physicians survey, 77% of est est practices for intra-health system atient. This team is dedicatedisstreamlinteam This to atient. ighly skilled transfer center coordinators.” t capacity or the hospital staff not hav or or the patient, the hospital staff will call p assigning quickly by throughput patient ing The The Transfer Center staff will then check man capacity with location’s the receiving agement team to gauge the receiving hos pital’s capacity and ability to accept the f the Transfer and Center to submit them a request. transfer gent patient due to the hospital operating due to operating the patient hospital gent a ing the capability to appropriately care bed Lyndon B. Johnson Hospital bed of B. Hospital Harris Lyndon Johnson If Health. one of the is to facilities unable provide care for an emergent or nonemer Employing the Transfer Process Transfer the Employing Intrasystem patient between Ben Taub Hospital and the 235- transfers occur ical case managers, and nonlicensedh but “The Transfer Center works 24 hours a 24 hours works day, Center “The Transfer seven days a staff mem of 14 a team have “We explains. week,” McMurray-Horton clin nurses, registered includes which bers, McMurray-Horton, Administrative Director Director Administrative McMurray-Horton, of Utilization who Management, oversees Center. Transfer entire the b at Harris Center and the Transfer transfers Health, The Academy spoke to Charlie at at its 486-bed Ben facility, Taub Hospital, to facilitate intra-health system and exter To nal transfers. learn patient more about Harris Harris Health System—a three-hospital healthsystem located Texas—Houston,in leverages an always-open Transfer Center ensuring patients get patients ensuring necessary treatment other to of transfers utilization the through system. health the within hospitals capable were not prepared for a significant patient were not for patient prepared a significant volume increase on their unit. One way can that this address is hospitals issue by tion. According to a 2014 American College College American a to 2014 According tion. of E responding ED physicians believed they Remaining prepared for patients presenting presenting patients for prepared Remaining to or the department inpatient emergency hospital is key to delivering high-quality popula patient diverse and care to a large Facilitating Intra-Health System by PatientTransfers Utilizing a Centralized Center Transfer 4 COPYRIGHT © DECISION RESOURCES, INC. ALL RIGHTS RESERVED. out the facility was also discovered to be be todiscovered also was facility the out Outcome & Utilization Strategies Strategies &Utilization Outcome e cmoet wr ctgrzd into categorized were components key These efficient. more department surgery the making of goal the achieving of facet different a on focused streamvalue Each for improvement. processes and then homed in on key areas FROM DELIVERY CARE PATIENT T is value.” increased tivity produc increased of result end the And ity. productiv helps increase services andtime peoples’ in Minimizing redundancy value. peopledoing the same thing, that’s wasted to time,” Dr. McNelis says. “If you have three “ vices from an anesthesiologist. ser receive to was whopatient a for ance members w staff multiple analysis, tional observa through example, For sibilities. was redundancyandconfusion respon instaff inefficiency such One department. surgical the withinnon-value-added work found to be the largest source of waste and a stream value the through processes gical assessing inefficienciesAfter sur within Work Added Waste and Non-Value- Decreasing clinic to discharge from recovery room. presentationto from process the through patient the of movement actual the and practices,blockscheduling, turnover time, issues they identified, including scheduling Jacobi initially completed 11 RIEs based improved on at be leaders implemented. Department and can how processes determine to particular team a by analyzed experiments monitored heavily are which v organized Jacobi stream, peri value operative each within inefficiencies resolve To physician-related issues in the OR. physician-relatedi processing, operative peri streams: value perioperative three se i te prtn ro, n non- and room, operating the in ssues In a hospital, there is a certain value placed arious rapid improvement events (RIE), (RIE), events improvement rapid arious he act of maneuvering patients through patients maneuvering of act he nalyses, physical redundancies were were redundancies physical nalyses, r fud o e ekn mdcl clear medical seeking be to found ere VALUE STREAM VALUE PATIENT CARE DELIVERY CARE PATIENT

ON PAGEON 1 • Clinical Processes – for Performance Improvement Performance –for Processes Clinical ------i hospital. To streamline patients’ routes routes patients’ streamline To hospital. the in floors separate several on located r appointments and make to process uling sched its streamlined Additionally,Jacobi improves system throughput.” McNelis says. “It does make a and difference youputyourself theinpatient’s shoes,” Dr. geographic layout or route the patient walks, “Whenyoumakechanges simple as the as between parts of the walk department. to required exertion and thefacility and limited the amount oftime navigatingpatientconfusionindecreased andconsolidated to one floor. This change remodeled was department three- surgical floor the appointments, surgery during ceuig rcse, n maneuvering and processes, time,scheduling turnaround throughput, patients’ the streamlining by times wait decrease toable was Jacobi initialRIEs, theDuring moving forward.” keep and lessons your from experiment Learn phase. rapid fail, the to during afraid especially be “Don’t so says. McNelis valuable, Dr. involved,” everyone get to is sure make opinion “Everyone’s members on the Lean team. staff appointed the assist to champions as them designate and RIEs surgical in assistants physician include to beneficial it found Jacobi issues, these resolve To the continuous education of new residents. necessitatingtime,of period specific very a only for onsite were individuals because these RIEs the in involve to difficult especially proved residents hospital’s the particular,turnover.In staff to due efforts one of its largest challenges was sustaining ThroughoutJacobi’smethods, Lean of use Sustaining Improvement Initiatives reduce patient confusion and stress. to helped whichout, fill to required were patientsforms ofamount the decrease to hospital the allowed also consolidation the minimizetomultipledaysame visits.This for booked be could appointments certain that so schedules staff adjusting and scheduling block improvingincluded nefficientsurgicalunitswerethebecause mnes oe fcet Te change The efficient. more eminders - published monthly by Healthcare Business Insights Business Healthcare by monthly published one fiscal year with the integrated RIEs and was able to sustain positive outcomes after overcome the staff turnover setback, Jacobi physicianchampionsassistantitsto from surgicaltheonfloor. Withbuilt-in support ing simulation tactics with its current current its L with tactics simulation ing integrat By OR. the in times turnaround decreased hospital the rate.Furthermore, completion form an processing patient and 82% utilization, OR a in times, increase 25% flow patient in improvement 50% a included outcomes change These quality changes. n smtms o bcsie s you so always have to be on top backslide, of it.” you sometimes and strides great make you “Sometimes says. it,”McNelisDr.of importance the ofsight lose not do and process the with “Stick c surgical in quality overall the and ciency effi department improve may systems a areas, targeted in initiatingchangesyses, anal stream value conducting By insight. valuable provide can Hospitals + Health p setting,thesurgical the inprojects ciency effi and to methodologies Lean attemptingimplement organizations other For department by times 11%.turnaround surgery overall and decreased minutes 18.4 to minutes 32.3 from unit orthopedics its in time turnaround are services. nd decreasing waste, hospitals and health ractices of Jacobi Medical Center of NYCCenter ofMedical Jacobi of ractices ean RIE principles, Jacobi decreased decreased Jacobi principles, RIE ean targeting improvement opportunities. improvement targeting i the indicating processes, several in comes out improved saw Center Medical Jacobi RIEs, conducting of year fscal one After mportance of identifying inefciencies and and inefciencies identifying of mportance 22% Services at Jacobi Medical Center Medical Jacobi at Services Increased OR OR Increased Utilization Outcomes of Applying Lean Lean Applying of Outcomes Methodologies in Surgical Surgical in Methodologies EXIT Source: Castaldi M et al. (2016) [email protected] [email protected] Turnaround Time Turnaround 11% Improved Improved • 888.700.5223

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