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Improving clinical communications at Dignity Health’s St. Joseph’s Medical Center October 2012 A value analysis of PerfectServe’s impact on hospital operations

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Page 1: Improving clinical communications at Dignity Health’s St ......Executive summary. The case for improving clinical communications. 4. U.S. hospitals waste approximately $12 billion

Improving clinical communications at Dignity

Health’s St. Joseph’s Medical Center

October 2012

A value analysis of PerfectServe’s impact on hospital operations

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Contents

Executive summary 3

The case for improving clinical communications 3

Key technologies enabling clinical communications improvement 6

DignityHealth’sSt.Joseph’sMedicalCenter 7

Studyapproachandmethodology 8

Benefitsanalysis 11

Closingremarks 21

AboutMaestroStrategies™ 22

AboutPerfectServe® 22

References 23

Publishedasasourceofinformationonly.Thematerialcontained hereinisnottobeconstruedaslegaladviceoropinion.

©2015PerfectServe,Inc.Allrightsreserved.PerfectServe®isaregisteredtrademarkandPerfectServeSynchrony™andProblemSolved™aretrademarksofPerfectServe,Inc.

perfectserve.com | 866.844.5484 | @PerfectServe

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Today’shealthcaredeliverylandscapeischangingrapidly.Withhealthcarereformlegislationandhealthcarepaymentreformattheforefront,moreemphasisisbeingplacedonefficientcoordinationofcareacrosssettingsandensuringaccesstocare.

Effectivecommunicationswithinandamongthecareteamareessentialtosafe,highqualitycare,efficientcarecoordinationandaccessmanagement.

PerfectServe,acompanythatprovidesanext-generation,clinicalcommunicationsplatformwhichmakesiteasyforclinicianstoconnectwitheachother,engagedMaestroStrategies,anationallyrecognizedhealthcarestrategyandtransformationfirm,tocompleteanindependent,third-partyevaluationofPerfectServe’simpactandvalueonhospitaloperations.

Thispaperexaminestheexperienceofonehospital,St.Joseph’sMedicalCenterofStockton,California,anditsinitialimplementationofthePerfectServeclinicalcommunicationsplatform.

MultiplebenefitsassociatedwiththePerfectServeimplementationwereidentified,includingenhancedpatientthroughput,improvedclinicaloutcomesandpatientsatisfactionrelatedtoquietnessscores.

Measuringthequantitativeandqualitativeimpactsbetweenadefinedpre-implementationperiod,andafive-monthpost-implementationperiodconfirmedsignificantchangesinoperatingperformance.

AsSt.Joseph’sMedicalCentercontinuestoexpandoncurrentadoptionanduseofthePerfectServeplatform,evengreaterbenefitsandvalueareanticipatedbytheleadershipteam.

Intoday’schallenginghealthcareenvironment,clinicianshavelimitedtimetospendwithpatients,makingcommunicationsbetweenclinicians,regardlessofthecaresetting,criticaltoensuringthebestoutcomeforthepatientandtheprovider.Unfortunately,thehealthcaredeliverysystemoftodaylacksstandardizedprocessesforcollaborationbetweencolleaguesbecausetherearelimitedtoolstoenableclinicianstoeffectivelyfilter,manageandprioritizecommunications.

Limitationsoncommunicationshaveasignificantimpactonbothpatientoutcomesandproviderproductivity.Accordingtooneestimate,

Executive summary

The case for improving clinical communications

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U.S.hospitalswasteapproximately$12billionannuallyduetopoorcommunicationamongcareproviders;54%ofthewastecanbeattributedtoanincreasedlengthofstayandassociatedincreasedcostofcare.1

Inaddition,multiplestudiesindicatethat70-90%oferrorsareduetopoorcommunicationbetweenprofessionals.2Actualversuspredictedmortalityratesvarysignificantlybasedontheeffectivenessofcommunications(41%worsethanpredictedforpoorcommunicationsand58%betterthanpredictedforexcellentcommunications).3

Nurse-to-physiciancommunicationscanbeparticularlyproblematic.Astudyofnurse-to-physiciancommunicationfoundthatbetween10%and40%oftotalcommunicationtimewasspentattempting,butfailing,tocommunicatewiththecorrectprovider,whichmeantnurseswerespendingvaluabletimesearchingforinformationtodeterminetheappropriateproviderand/orphonenumber.4

Infact,14%ofallpagesweresenttothewrongphysician—aphysician/residentwhowasscheduledtobeoff-dutyoroutofthehospital—and47%ofthosewereurgentmessages.5“Theabilityofphysiciansandnursestoworkasaunifiedteamisessentialtoimprovedoutcomes,errorandriskreductionandoptimumcare.”6

Astudyonthebarriersofeffectivephysicianandnursecommunicationinthelong-termcaresettingshowedthatthethirdmostfrequentbarrierwasdifficultyreachingthephysician.7

Physician-to-physiciancommunicationsarealsoplaguedwithchallenges.Communicationhasbeenidentifiedasamajorcontributingfactorintheoccurrenceofsentinelevents.Handoffsandtransitionsarespecifictypesofcommunicationthatrequirethesuccessfultransferofinformationtoensuresafe,effectivepatientcare,andcurrently,thereisnostandardforcommunicatinginformationbetweenahospitalistandtheprimarycarephysician(PCP)atdischarge.8

Infact,effectivewaystomanagephysiciantransitionsandhandoffsarenotbeingtaughttotoday’sresidents.OfattendingphysiciansattheUniversityofColorado,Denverhospitals,only6%saidtheyhadbeenformallytaughthandoffsinmedicalschool,andonly28%hadbeenformallytaughthandoffsinresidency.9

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Theuseofhospitalistsasinpatientcaregiverswithdischargetoprimarycarephysiciansforpost-dischargefollow-uphasdemonstratedthatphysician-to-physiciancommunicationshavebecomeincreasinglyimportant.Accordingtoonesource,directcommunicationbetweeninpatient(hospitalist)physiciansandPCPsoccurredduringonly3-20%ofhospitalizations.Atthetimeoffirstpost-dischargevisit,PCPsinthestudyhadreceivednowrittendischargeinformationinupto50%ofpatients.Only17%ofPCPsreportedreceivingnotificationfromhospitalistsaboutdischarges.10

Failuretofollowthroughwithhospitalistdischargeorders(durablemedicalequipment,follow-upvisitswiththePCPandothertherapiesorclinics)leadstoavoidableemergencydepartment(ED)visitsandre-hospitalizations.11Infact,between19%and23%ofpatientsrecentlyhospitalizedexperiencedanadverseeventafterdischargeduetosomeformofinadequatepost-dischargefollowup.12Theadverseeventsfrequentlyoccurwithinthefirstfivedaysafterdischarge.13AccordingtoCMS,infiscalyear2009,13%ofreadmissions(worthapproximately$12billion)werepotentiallypreventable.14

Communicationbreakdownsalsothreatenthesafetyofsurgeries.Areviewof444casesshowedthemostcommoncommunicationbreakdownsinvolvedfailureofaresidenttonotifytheappropriateattendingsurgeonofacriticaleventandnonexistentattending-to-attendinghandoffs.15

Finally,professionaloutcomemeasuressuchasjobstress,groupcohesionandnursesatisfactionwithdecision-makingarealsoinfluencedbynurse/physiciancollaboration.16

WiththeadventofhealthcarereformandaccompanyingnewmodelsofreimbursementincludingbundledpaymentsandValue-BasedPurchasing,transitionsofcaremustbemoreeffectivelycoordinated.Effectivecommunication between clinicians across the care continuum is essential forcoordinatingtransitions.

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Thehealthcareindustrycontinuestoemploymultiplepointsolutionsandtechnologiessuchascallcentersandansweringservices,overheadpaging,securetextmessaging,web-scheduling/pagingsoftware,pagersandwirelessphones.

Thechallengewithmanyofthesetoolsisalimitedabilitytoaddressthecomplexityinherentinclinicalcommunicationprocesses—notonlywithinthehospitalbetweenoneormoresiloeddepartments,butacrossmultiplecaresettings,includingambulatory,acutecareandpost-acutecareenvironments.

Itisdifficultforclinicianstokeepupwithmanualphonelists,callschedulesandothersourcesofinformationthatarerequiredtoestablishactualcontactbetweenclinicians.

Communicationsdirectedtophysicianscanbeespeciallychallengingbecausephysiciansmustcontroltheiraccessibilityinordertomanagetheirtimeeffectively.Tothisend,physiciansoftenerectbarrierstoprotectthemselves(e.g.,third-partyintermediariessuchasansweringservicesandofficestaff),yet,inmanycases,thesebarrierscreatefriction,whichimpedescommunicationandcompromisescare.

Theemergenceandacceptanceofsmartphonesandtabletsinhealthcaresettingshasbeenessentialtodrivingnotonlyproviderproductivity,butimprovingthecoordinationofcareacrosssettings(physicianoffice,ambulatorysettings,acutecare,long-termcareandothers).Improvementinbothtechnologyandbandwidthcontinuestodrivemoresophisticatedmethodstoprovideeffectiveclinicalcollaborationandbetterpatientcare.

Anewtechnologyisemerging,whichisbuiltuponasecureandcomprehensivecommunicationsplatform,coupledwithadecisionrulesengineandpurposefulcommunicationsprocessdesign,optimizingcallandmessageroutingtoensureaccuracyandreliability;and,thus,enablesclinicianstomakedecisionsmorequickly.

Thisplatform,withbuilt-inalgorithmsthatdefineanorganization’sclinicalcommunicationsprocesses,facilitateseffectiveclinician-to-cliniciancontactbasedonanumberofvariables,suchastheoriginoftheinteraction,theoriginator’srole,thenatureandurgencyoftheinteraction,patientidentity,timeofday,dayoftheweek,callcoverageschedulesandtheclinician’spreferredcontactmethod.

Key technologies enabling clinical communications

improvement

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St.Joseph’sMedicalCenterisanot-for-profit,359-bedhospitalinStockton,California,andisamemberofDignityHealth(formerlyCatholicHealthcareWest),whichincludesmorethan40hospitalsandcarecentersinCalifornia,NevadaandArizona.St.Joseph’sMedicalCenterhasover400physiciansonstaffandoffersspecializedservicesincardiovascularcare,comprehensivecancerservicesandwomenandchildren’sservicesincludingneonatalintensivecare.

Thechiefmedicalofficer,Dr.SusanMcDonald,identifiedtheneedtoimprovecliniciancommunicationsasacriticalissueatSt.Joseph’sMedicalCenteranddeterminedthat,whileprocessimprovementwasneeded,technologywouldbethekeytomanagingandmaintainingthecomplexcommunicationprocessalgorithmsuniquetophysicians.

Physicianfocusgroupsandinterviewswithnursemanagers,nursesandunitsecretariesthroughoutthehospitalrevealedthatwaste,frustrationandriskrepeatedlyarosefromSt.Joseph’sMedicalCenter’sexistingclinicalcommunicationsprocesses.Thesamegroupexpressedadesireforchangeandfeltstandardizingcommunicationsonasingle,intelligentplatformcouldhelpthemmeetthefollowingorganizationalgoals:

• Improvepatientsatisfactionbyreducingnoiseassociatedwithoverheadpagingofphysiciansinthehospital.

• Buildalignmentbetweenthehospitalandthemedicalstaff,andmakeiteasiertopracticeatSt.Joseph’sbyprovidingphysicianswithasingle,integratedsolutiontomanageallclinicalcommunications(whetherfromcolleagues,patientsorhospitalstaff).

• Improvepatientoutcomesbyreducingthenumberofrapidresponseteamcalls,codeblueeventsandmortalityratesthroughdecreasedtimetointerventionandtreatmentwhenapatient’sconditionisdeteriorating.

Dignity Health’s St. Joseph’s

Medical Center

“AsthenewchiefmedicalofficerforSt.Joseph’s,oneofthefirstissuesIwantedtoaddresswasimprovingcommunicationsbetweenphysiciansandbetweenphysiciansandhospital-basedstaff.Theneedwasapparent,andthesolutionneededtobetechnology-based.”

SusanMcDonald,M.D. Chief medical officer, St.Joseph’sMedicalCenter

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• Improvepatientthroughputbyrefiningprocessesdependentonclinicalcommunications,resultinginreducedlengthofstaywithininpatientunitsandimprovedEDthroughput.

St.Joseph’sMedicalCenterelectedtodeployPerfectServebecauseofitsabilitytosimplifyandstreamlinecommunicationprocessessoclinicianscanbetterdirectandmanagepatientcare.

Unlikethepointsolutionsdiscussedintheprevioussection,PerfectServebroughtthreecapabilitiestoSt.Joseph’sthatareessentialtoeffectivelymanagethecomplexityinherentinclinicalcommunicationprocesses:

• Asecureandcomprehensivecommunicationsplatformwithanadvancedrulesenginepurpose-builtformedicine

• Aserviceorganizationtoquicklydriveprocessimprovementstandardizationacrosstheenterpriseandsustainitovertime

• Asuiteofintegrated,cloud‐basedapplicationsthatmakesiteasytoconnectinterdependentcliniciansinanycaresetting

PerfectServeengagedMaestroStrategies,anationally-recognizedhealthcaretransformationfirm,toprovideanindependent,third-partyevaluationoftheimpactofPerfectServeonhospitaloperationsatSt.Joseph’sMedicalCenter.

Withthecooperationofthehospitalleadershipteamandsupportpersonnel,MaestrowasabletoassessboththequalitativeandquantitativeimpactofPerfectServeandthenewcommunicationprocessesitenabledinanacutecaresetting.Thetimelinebelowrepresentskeymilestonesinthisassessment.

Study approach and methodology

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Measurement period

Pre-implementation visit

Inordertounderstandthecurrentoperatingenvironmentaroundclinicalcommunications,MaestroStrategiescompletedatwo-daysitevisittoSt.Joseph’sMedicalCenterinOctober2011.Interviewswereconductedwithkeyleadership,nursingunitmanagersandphysicians.

Thepurposesoftheinterviewsweretwofold:1)togaininsightintothechallengeswiththecurrentmeansofcommunicationsbetweenclinicians,and2)todocumentexpectedbenefitsassociatedwithimplementingPerfectServe.Inadditiontointerviews,directobservationswereconductedonseveralnursingunitsandotherpatientcareareas.

Development of benefits hypotheses

Afterspendingtwodaysonsite,theMaestroteamcombinedandanalyzedtheinterviewresultsandobservationswithpotentialbenefitscitedfromliteraturereviewandresearchtodevelopanextensivelistofbenefithypotheseswhichcouldbetested.Thislistwasthenrefinedtotietoandreflectkeyobjectivesthatthehospitalleadershipteamwishedtoaccomplish.

Baseline measurement

Oncethepotentiallistofbenefitswasdeveloped,thedatarequiredtomeasurethosebenefitswasidentifiedandbaselinedatawasrequestedfromSt.Joseph’s.Inordertoaccountforseasonality,afullyearofdatafromtheperiodpriortothePerfectServeimplementationwasrequested.

Nov ’10 Jan ’11

Pre-implementa�onmeasurement period

Mar May Jul Sep Nov ’11 Jan ’12 Mar

Post-implementa�onmeasurement period

PerfectServe go-liveNovember 2, 2011

Site visit

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Whereavailable,thedatawassubmittedonamonth-by-monthbasis.Thedatawasexaminedtodeterminecompletenessandsuitabilityforinclusioninthepost-implementationanalysis.Basedontheavailabilityofanddifficultyinacquiringthedata,somehypothesizedbenefitsweredroppedfromthelist.

Implementation of PerfectServe

ThePerfectServeteamspentseveralmonthspreparingforago-livedateofNovember2,2011.Pre-implementationactivitiesincludedthetechnicalaspectsofconfiguringthePerfectServehospitalapplicationsforbothWebandphoneaccess.SpecialemphasiswasplacedonexpandingtheuseofwirelessSpectralinkphonesbynursingstaff.

Afteranalyzingkeycharacteristicsofthemedicalstafftoidentifythosephysiciansmostlikelytodrivehighutilization,PerfectServeimplementationconsultantsbeganmeetingwithphysiciansandtheirstafftodocumenteachpractice’scurrentanddesiredstatecommunicationsprocessflows,callschedulestructureandeachphysician’sandmid-levelprovider’spersonalcontactpreferences.TheconsultantsthenassembledthisinformationwithinthePerfectServeplatformforeachpracticeworkgroupandmedicalstaffmember.

Priortogo-live,numerouseducationsessionswereheldregardingthefollowingtopics:

• Howtomodifyandmaintaincallschedulesandactivatedifferentpre-definedcontactprocesses

• Howtousethemobileapp,voiceandWebinterfaces

• Whattoexpectfromthenewcommunicationprocesses

• WhenandhowtousePerfectServe’shelpcenter

Duringthego-live,thePerfectServeteamwasonsiteroundinginthehospitalandmeetingwithphysicians,staffmembersinthehospitalandpracticeoffices,asrequiredtoaddressissuesassociatedwiththenewplatform.Overthefive-monthpost-go-liveperiod,PerfectServeconsultantscontinuedtoworkwithclinicianstooptimizetheircontactprocessesandhelpthemmaximizetheuseofPerfectServe’scapabilities.

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Post-implementation measurement

Twoperiodsoftimewereselectedtomeasurepost-implementationimpactsofthePerfectServeprocess.An“earlyterm”measurementwasconducted,whichutilizeddatafromthefirst90-daypost-go-liveperiod.Amid-termmeasurementwasmadeforthesubsequent60days.Intotal,fivemonthsofpost-go-livedatawereexamined.Inadditiontothedataanalysis,follow-upinterviewswereconductedwithkeymembersoftheleadershipteamtobetterunderstandthebenefitsrealizedatSt.Joseph’sMedicalCenter.

InthefivemonthsfollowingthePerfectServeimplementation,St.Joseph’sMedicalCenterdemonstratedsignificantimprovementinclinicalprocessesdependentuponeffectiveandefficientcommunications.

WithPerfectServehandlingapproximately14,000clinicalcommunicationeventseachmonthduringthestudyperiod,thebenefitsachievedincludestandardizationofcontactprocessesandproceduresacrossthemedicalstaff.

Benefitsanalysisfocusedinthefollowingareas:

• Quietnessscores—patientsatisfaction

• Patient outcomes

• Patient throughput

Thenewcommunicationprocessesdramaticallyreducedthird-partyhandoffsandoverheadpaging,andeliminatedtheneedtomaintainandrefertomanuallistsandcallschedules.ThisinformationisallbuiltintoPerfectServealgorithms,allowingcallsandmessagestorouteaccordinglywithgreateraccuracyandreliability.

Quietness scores—patient satisfaction

PriortoPerfectServe,overheadpagingwastheprimarymeansofinitiatingasearchforaphysicianinthehospital.Overheadpagingwasidentifiedasadissatisfierforbothpatientsandphysicians.Onewaytomeasuretheeffectofreducedoverheadpagingistousepatient

Benefits analysis

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satisfactionscoresrelatedtonoise.

TheHospitalConsumerAssessmentofHealthcareProvidersandSystems(HCAHPS)surveyiscompletedbypatientsortheirfamiliesatdischargeandconsistsofaseriesofquestionsaboutthepatientexperiencewhileinthehospital.

Thesurveyspecificallyasks:“Duringthishospitalstay,howoftenwastheareaaroundyourroomquietatnight?”Thepercentagescalculatedareforpatientswhoanswered“Always.”ForSt.Joseph’sMedicalCenter,thisparticularmetricwasconsistentlybeloworganizationaltargetsandwaspartofthereasonfordeployingPerfectServe.Scoresforquietnessimprovedby24%fromthepre-implementationperiodascomparedtothesameperiodpost-implementation.

“Overheadpaginghasalmostbeencompletelyeliminated,makingthehospitalaquieterplaceforourpatientsandstaff.Wearefindingthatthisisyieldinghigherpatientsatisfactionwithquietnessofthehospital.We’reexcitedaboutallthatwehaveachievedsofarwithPerfectServeforourphysiciansandnurses.”

DonWiley President & CEO, St.Joseph’sMedicalCenter

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Percent of patients who responded to the statement: “Room was always quiet at night.”

ForSt.Joseph’s,thisrepresentsanestimated$95,000inrevenue.ThequietnessmeasureispartoftheaggregatedscoreusedtodeterminereimbursementunderValue-BasedPurchasingandcanpotentiallyaffectoverallMedicarereimbursement.UsingMedicareweightingschemes,theamountatriskforSt.Joseph’sMedicalCenterspecificallyrelatedtoquietnessscoresis$95,000peryearbasedon2011Medicarevolumesandcharges.

Patient outcomes

Communicationsrelatedtochangesinpatientconditionorpatientdeteriorationarecomplexandinvolveasignificantamountoftime.Directpatientcareprovidersmustleavethepatientbedsidetoinitiatecontactwiththephysiciantoobtainorderstointervenewhenapatient’sconditionchangesordeteriorates.Enhancedandtimelycommunicationbetween

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HCAHPS scores for quietness have improved 24% post

implementation compared to the same period in the prior year.

For St. Joseph’s this represents an

estimated $95,000 in revenue.

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thedirectcareproviderandthephysiciancanreducetimetotreatmentwhenpatientconditiondeteriorates.Moretimelymedicalinterventionmayalsoreducetheneedtoinitiatecallfortherapidresponseteam(RRT)andcanalsolessenthefrequencyofcodeblueevents.

Topositivelyimpactpatientoutcomesinadditiontostreamliningthenurse-to-physiciancontactprocess,PerfectServeworkedcloselywiththenursingstafftoincreasewirelessSpectralinkphoneadoptiontobetterfacilitatedirectphysician-to-nursecommunicationwhenarapidresponsewasrequired.OneachSpectralinkphone,PerfectServecanbeaccesseddirectlyviaadirectdialnumber.WhenanurseinitiatesacallintoPerfectServeusingaSpectalink,thenumberassociatedtothatnurse’sphoneisautomaticallyembeddedintothemessageforthephysician,which,inadditiontoprovidingautomaticdocumentation,makesthereturncalleasyforthephysician.

ThenumberofRRTcallsandcodeblueeventswasexaminedonaquarterlybasisandthenumberofcallsandcodesper1,000dischargeswascalculated.TherateofbothRRTcallsandcodeblueeventsdecreasedafterthePerfectServeimplementation.BecausedatawasonlyavailableonaquarterlybasisandthePerfectServeimplementationoccurredinthemiddleofaquarter,aspecificperiodoftimewasconsideredatransitionperiod.

PriortoPerfectServe,therateofRRTcallsoversixmonthsaveraged29callsper1,000discharges.Post-implementationtheratedroppedto28callsper1,000discharges,whichrepresentsa3%improvement.

Similarly,theaveragerateofcodeblueeventsper1,000discharges was14pre-implementationanddecreasedto11afterPerfectServe,a24%improvement.

Combined,thesestatisticsimplythatshortercommunicationcycletimesarelikelycontributorstomoretimelyinterventionsforpatientswhoseconditionsaredeteriorating.

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RRT and code blue calls per 1,000 discharges

Arelatedstatisticistheimprovementinoutcomesforpatientswhohaveacodeblueevent.Thepercentofpatientsdischargedaliveafteracodeblueeventimprovedfromanaverageof24%pre-implementationto29%post-implementation.Furthermore,asconsumersscrutinizeindividualhospitalperformancethroughpubliclyavailabledatasuchasHospitalCompare,statistics,suchasmortalityrate,havethepotentialtodriveproviderchoiceandimpactmarketshare.Inaddition,payersusehospitaloutcomesandperformanceintheirnegotiationprocesswithproviders,whichdirectlyimpactshospitalrevenue.

The rate for both rapid response team (RRT) and code blue events decreased after the PerfectServe implementation.

Average RRT calls per 1,000

discharges dropped 3%.

Average code blue events per 1,000 discharges dropped 24%

Pre-implementation

RRT Code blue

Post-implementation

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Percent of patients discharged alive

Patient throughput

Clinician-to-cliniciancommunicationisahighfrequency,highlyvariableactivityinhospitaloperations.Assuch,itsefficiencyandeffectivenesshaveasignificantimpactonpatientthroughputacrosstheacutecaresetting.

Nursesneedtoconnectwithphysicianstoobtainorderssotheycaninitiatecare.Whencommunicationcycletimesareunnecessarilylong,actionisdelayed,whichimpedesthroughput.Apatientwhoisreadytobedischarged,butiswaitingforfinalapprovalfromeithertheattendingoraconsultingphysician,maynotbeabletobedischargedinatimelymanner,resultinginanadditionalnightinthehospital—impactinglengthofstay.

Inaddition,patientsbeingadmitted(especiallythroughtheED)mayhavetowaitforanavailablebedonanursingunituntilexistingpatientsaredischarged.This,inturn,impactsEDthroughputaspatientswaitingtobe

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The percent of patients discharged alive after a code blue event improved from

an average of 24% pre-implementation to 29% post-implementation.

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seencannotbeplacedinanexaminationroomuntilpatientswaitingonadmissionhavebeenmovedtoinpatientunits.

Manytimes,extendedwaittimesintheEDresultinpatientsleavingwithoutreceivingcare.Inaddition,therearetimestheEDwillhavetodivertambulancestootherfacilitiesasithasnocapacitytoreceiveadditionalpatients.Thisresultsinlossofrevenuetothehospital,aswellaspotentiallycompromisingpatientsafety.

Reduced length of stay

Theaveragelengthofstay(ALOS)forthepost-implementationperiodwas4.68dayscomparedto4.75daysforthesameperiod(November-March).Thisrepresentsa1.6%decreaseinALOS.

Average length of stay (days)

ThishassignificantimpactoncontributionmarginforpatientswhosereimbursementisDRG-based(MedicareandMedi-Cal).

Average length of stay (ALOS) decreased 1.6% after the

PerfectServe implementation.

This has a significant impact on contribution margin for DRG-based

reimbursements, and represents a potential savings of $1,982,000 for St. Joseph’s.

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ForSt.Joseph’s,potentialsavingsrelatedtoreductioninALOSaresummarizedinthistable:

Length of stay improvement value analysis

AnnualizednumberofDRG-baseddischarges 11,605

Averagevariablecost/day $2,358

Averagelengthofstaypre-implementation 4.754days

Averagelengthofstaypost-implementation 4.682days

ReductioninLOS 0.072days

Estimated potential savings: (0.072 days) x ($2,358 cost/day) x (11,605 discharges) $1,981,552

Emergency department throughput

St.Joseph’sMedicalCenterhasanEDtriagesystemthatensureseverypatienthasabriefdiscussionwithaclinicianonceheorsheisregistered.However,dependingontheurgencyofapatient’sconditionattriage,theymaybeaskedtositinthewaitingroomuntiltheycanbeseen.Formanypatients,thewaittimescanbelongandtheyultimatelyleavewithoutreceivingcare.

The number of patients who left the ED without receiving care (for datacollectionandanalysispurposes,leavingagainstmedicaladvice(AMA)wasusedasaproxyforleavingwithoutreceivingcare)duringthepost-implementationperiodwas786comparedto986forthesameperiodpre-implementation.Thisrepresentsa20%decreaseinpatientswholeftAMA.

ThereductioninnumberofpatientsleavingAMAalsocorrelates(inversely)totheincreaseinnumberofpatientsseenasdetailedinthegraphbelow.

AsthenumberofpatientsleavingAMAdecreased,thenumberofpatientsseenandtreatedincreased.Theincreaseinthenumberofpatientsseenduringthepost-implementationperiodcomparedtothesamemonthsinthepre-implementationperiodwas11%.

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Inaddition,theamountoftimespentondiversionhasdecreased.ThecombinationofthesethreestatisticsdemonstratethatSt.Joseph’sMedicalCenterhasbeenabletodramaticallyimpactEDthroughput—byseeingmorepatients,byreducingthenumberofpatientsleavingAMAandbylimitingtheamountoftimetheEDisondiversion.

Percent improvement in ED patient throughput

Theimplicationsforthisarebroad,aspatientcare,patientsafetyandpatientsatisfactioncanbepositivelyimpactedandtheorganizationcanrecognizerevenueopportunities.

After the PerfectServe implementation, the ED experienced 20% decrease in patients

who left against medical advice (AMA).

This correlates to an 11% increase in patients seen and treated.

In addition, the amount of time spent on diversion decreased by 50%.

Left AMA Patients seen Diversion0%

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ED patient throughput improvement value analysis

Averagedirectmargin/EDoutpatient $355

NumberofpatientswholefttheEDAMAannuallypre-implementation 2,076

AnnualexpectedpatientsleavingAMAafterimplementation 1,655

ReductioninleftAMA 20%

Incrementalpatientsexpectedpost-implementation 421

Estimatedpotentialannualincrementalmargin(421patients)x($355directmargin/patient) $149,386

Benefits summary

St.Joseph’sMedicalCenterrealizedavarietyofbenefits,bothquantitativeandqualitative,throughtheprocessimprovementsPerfectServeenabled.

Thematrixbelowsummarizesthebeforeandafterimprovementandthefinancialimpactwhereapplicable:

Aspost-implementationinterviewswereconductedwithhospitalleadership,additionalbenefitsassociatedwiththePerfectServesolutionwereidentified.

Summary value analysis Before After % Improvement Impact

Reducednoise,increasedHCAHPS 38% 48% 24% $95,000

Reducedaveragelengthofstay 4.75 4.68 1.6% $1,981,000

DecreaseinEDpatientsleavingAMA 2,076 1,655 20%

$150,000

IncreaseinEDpatientsseen 19,762 21,875 11%

ReducedEDtimespentondiversion 11,282 5,594 50%

ReducedRRTcalls/1,000discharges 29 28 3% Quality

Reducedcodeblueevents/1,000discharges 14 11 24% Quality

Increased%dischargedaliveaftercode 24% 29% 21% Quality

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Forexample,byprovidingnursestheabilitytoeasilyreachtheadministratoroncallviaPerfectServe,floornurseswereabletoresolveoperationalissuesmorequickly.Whilethereisnotametrictodescribethisbenefit,leadershipseesclearadvantagesinsimplifyinglinesofcommunication.

HealthsystemsthatusePerfectServetostandardizeexistingclinicalcommunicationprocesses—andenablenewprocesses—havethepotentialtosignificantlyimpactpatientcareacrossthecontinuum.

Asdocumentedinthispaper,thevalueofPerfectServe’sofferingshasclearlybeendemonstratedatDignityHealth’sSt.Joseph’sMedicalCenter.

Clinician-to-cliniciancommunicationisahighfrequency,highlyvariableactivity,which,whenunderthestatusquo,negativelyaffectshospitaloperationsandthequalityofcare.

Effectiveclinician-to-cliniciancommunicationcanbedramaticallyimprovedbydeployingasingleplatformsolutionthatenablesefficientprocessestomakeiteasytoconnectcliniciansacrossmultiplecaresettings.

Whenclinicalcommunicationprocessesareenabledwithrules-basedintelligenttechnology,communication,collaborationandcoordinationofcareoccurmorequickly.Thispositivelyimpactspatientoutcomes,patientthroughputandpatientandcareteamsatisfaction.

ThispaperrepresentstheearlymeasurementofresultsexperiencedbySt.Joseph’sMedicalCenter.ThereisanexpectationacrossseniorleadershipthatcontinuedeffortstoapplyPerfectServetogreaternumbersofcommunications—dependentclinicalprocesseswillleadtoanincreasedimpactwithexistingidentifiedbenefits,andthattherewillbe

“Whilewecannotattribute100%oftheimprovementinkeymetrics(suchaslengthofstay)specificallytoPerfectServe,webelievethatithascontributedtotheseimprovementsandthatoverall,PerfectServehaspaidforitself.”

DonWiley President & CEO,St.Joseph’sMedicalCenter

Closing remarks

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additionalbenefitsthatwillbeidentifiedandquantified.

Whilethebenefitsmeasuredinthisstudywereconfinedtotheinpatientsetting,PerfectServe’splatformextendsbeyondthefourwallsofthehospitaltooutpatientandambulatorycaresettingsformanyofSt.Joseph’sphysicians.

ThereisfurtheropportunitytoexpandPerfectServecapabilitiestohelpenableclinicalintegration,carecoordinationandimprovementsincostandquality.

MaestroStrategiesisanationallyrecognizedhealthcarestrategyfirmspecializingintechnologydriventransformation.MembersoftheMaestroteamhaveservedasthoughtleadersintheareaofreturnoninvestment(ROI)andbenefitsrealizationforovertenyears.Authorsoftheaward-winningbookseriesonreturnoninvestmentofHIT,Maestroworkswithhealthcareleaderstoplanforvalueandthenmanagethatvalueintoreality.Formoreinformation,pleasevisit:www.maestrostrategies.com.

Servinghealthsystemstoimproveoutcomesandefficiency,PerfectServe’ssecureandcomprehensiveclinicalcommunicationsplatformmakesiteasytoconnectcliniciansacrossthecontinuumsotheycanbettercoordinatecare.BasedinKnoxville,Tennessee,PerfectServeprocessesmorethan35milliontransactionsannually,connectingmorethan50,000physiciansinmorethan118hospitalsand14,000medicalpracticesacrosstheUnitedStates.Formoreinformation,gotowww.perfectserve.comorcall866.844.5484.

About Maestro Strategies

About PerfectServe

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1. AgarwalR,SandsDZ,Diaz-SchneiderJ.QuantifyingtheEconomicImpactofCommunicationInefficienciesinUSHospitals;Winter2008;CenterforHealthInformationandDecisionSystems,ResearchBriefing;Volume3,Issue1B.

2. TschannenD,KeenanG,AebersoldM,KocanM,LundyF,AverhartV.ImplicationsofNurse-PhysicianRelations-‐ReportofaSuccessfulIntervention;10/06/2011;NursEcon.2011;29(3):127-135.

3. TschannenD,KeenanG,AebersoldM,KocanM,LundyF,AverhartV.ImplicationsofNurse-PhysicianRelations-‐ReportofaSuccessfulIntervention;10/06/2011;NurseEcon.2011;29(3):127-135.

4. Dingley,Cetal.ImprovingPatientSafetyThroughProviderCommunicationStrategyEnhancements;AdvancesinPatientSafety:NewDirectionsandAlternativeApproaches.ARHQ;Aug2008.

5. HospitalMiscues:SendingPagestoDr.Wrong;TheWallStreetJournal;June8,2009.

6. CloughJ.CollaborationBetweenPhysiciansandNurses:EssentialtoPatientSafety;TheForum;May2008.

7. Tjia,Jetal.Nurse-PhysicianCommunicationintheLong-TermCareSetting:PerceivedBarriersandImpactonPatientSafety;JournalofPatientSafety;Sept2009.

8. Today’sHospitalistJune/July2004Hospitalistsandhand-offs:theproblemsthatplaguetheprocess;www.todayshospitalist.com.

9. ChuES,MiskyG,AndersonM,ManheimJ,ReidMB,AlbertR.;Unpublishedresults.

10. KripilaniSetal.Deficitincommunicationandinformationtransferbetweenhospitalbasedandprimarycarephysicians.JAMA2007;297:831-41.

11. Dingley,Cetal.ImprovingPatientSafetyThroughProviderCommunicationStrategyEnhancements.AdvancesinPatientSafety:NewDirectionsandAlternativeApproaches;ARHQ;Aug2008.

12. ForsterAJetal.Adverseeventsamongmedicalpatientsafterdischargefromhospital.CMAJ2004;170:345-349.

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13. ForsterAJetal.Theincidenceandseverityofadverseeventsaffectingpatientsafterdischargefromthehospital;AnnIntMed2003;138:1161-‐67.

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