Maryland Patient Safety CenterMinogue Award Application 2018

ORGANIZATION PROFILE

Organization Adventist HealthCare Washington Adventist Hospital

Contact Person Rosemarie Melendez

Title Director of Nursing Administration and Emergency Department

Address 7600 Carroll Avenue, Takoma Park, MD

Email RMelende@adventisthealthcare.com

Phone 301-891-5282

Solution Title Reducing ED Diversion through the use of the DMAIC process and the NEDOCS’ Surge Policy

FOCUS AREAPlease check all that apply

Communication Competency Assessment Core Measure Crisis Prevention Culture Diversity Education Emergency Department Environment Event Reporting

Falls Hand Hygiene Infection Prevention Information Technology ICU Laboratory Labor & Delivery Lean Operations Medical Equipment Medication Safety

Patient Assessment Patient/Family Involvement Pediatrics Pressure Ulcer Process Redesign Surgical Services Teamwork Workforce Other: Mission Integrity

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Reducing ED Diversion through the use of the DMAIC process and the NEDOCS’ Surge Policy

PROGRAM/ PROJECT DESCRIPTION INCLUDING GOALDMAIC: DEFINE PHASE

Adventist Healthcare’s Washington Adventist Hospital (WAH) is a 230-bed general medical and surgical hospital located in Takoma Park, Maryland. In 2016 the Emergency Department volume was over 47,500 visits, with a 14.5 percent admission rate.

As it is the case with most hospitals across the country, Washington Adventist Hospital had been experiencing an increase in ED visits year over year. During the 2016 calendar year the ED had averaged 86 hours per month on diversion. By January 2017 that number had nearly doubled to 148 hours, as the hospital experienced a steady surge in ED volumes.

An increase in diversion times, as a result of delayed throughput processes, was placing patients at risk; preventing them from being close to their families, trusted doctors, medical staff, and denying the receiving medical team full and immediate access to the patient’s medical history.

Using the DMAIC process - a data-driven strategy for continuously improving processes and driving innovation for optimal performance – 2016 & 2017 diversion data, Nursing and ED leadership worked together to identify the root of the problem driving the increase in ED diversion hours.

Once the root causes had been identified through the DMAIC process, the team worked to create a comprehensive and structured surge plan, following the National Emergency Department Overcrowding Scale (NEDOCS).

The goals of the project were to reduce the number of hours the ED went on diversion from 86 hours per month to 61 hours per month or 730 hours per year; using the NEDOCS system and adjusting it to fit our entity we used the score, as an objective measure of ED overcrowding.

By October 2017, after four months of implementating the new surge policy, we saw demonstrable and quantifiable improvement in our ED. Our diversion hours went from 148 hours in January to 16 hours at the end of October, leading to positive operational and financial performance.

PROCESS

LEAN SIX SIGMA: DMAIC

Using the DMAIC PI process, an experienced team of ED charge nurses, Administrative Supervisors, and the ED Director went through the process of:

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Defying the problem and scope of the project Establishing measurements for success and progress Analyzing contributing factors to isolate those that could be identified as root cause factors Selecting & testing countermeasures for improvement and developing and implementation plan Formulating a sustainability plan

NATIONAL EMERGENCY DEPARTMENT OVERCROWDING SCALE (NEDOCS) SCORE & SURGE POLICY:

During the Analyze and Improve phases, the teams researched innovative best practice countermeasures that could be implemented to drive breakthrough change and selected the NEDOCS’ score and Surge Policy in conjunction with the County/Hospital Alert Tracking System (CHATS ) to develop the surge criteria/levels:

The Emergency Department(ED) Charge Nurse is continuously looking at the NEDOC score that is calculated by the unit Support Coordinator in the department to see how busy the /department is getting. This calculation looks at;

The number of patients in the department Number of Vents/Bipap Longest Admit time Number of admitted patients Number of patients waiting to be seen Number of available ED beds

Based on the score the charge Nurse makes a decision on calling a huddle with key stakeholders to come up with a plan. She/he then huddles with the Emergency Department Physician in charge as well as the Administrative supervisor to see what the department’s needs are. This can consist of: an extra housekeeper, or an extra phlebotomist from the lab, on some occasions it may require the in-patient units to come pick up tier patients from the ED. Whatever the need identified is, a call is placed overhead throughout the hospital via our communication system 4164. The main objective is to identify the department’s need and try to resolve prior to going on diversion. During the times that we do go on diversion, we have been able to catch up quicker and spend less time on diversion.

The surge criteria looks at the number of patients waiting throughout the entire Hospital who’s disposition is “admission” to the hospital but have not moved into an in-patient bed. If the hospital has more than four patients waiting in any area, has not been assigned in-patient bed and has been waiting greater than four hours, the Administrative Supervisor can make the decision to surge any inpatient unit two patients over their matrix.

DMAIC: MEASURE PHASEMaryland Institute for Emergency Medical Services (MIEMS) uses CHATS

CHATS is a tool used by MIEMS that shows and generates reports on the current status of hospitals and counties in Maryland, including real-time listings of Yellow Alerts and Red alerts by hospital. It is updated every sixty seconds. In the state of Maryland hospitals are placed in one of five regions. Washington Adventist hospital is in Region V with twenty –five (25) other hospitals in Maryland. ED

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Leadership and MIEMS leadership meet on a monthly base to discuss Diversion hours; EMS units wait times per facility and working relationships.

Metric: Number of Diversion hours for Emergency Department

Target: 61 hours per month (Year-end total 730 hours)

World Class: 42 hours per month

Best Competitor: 47 hours per month

Desired Trend: Downward

Baseline: 86 hours per month (based on average of 2016 data)

Numerator: None

Denominator: None

Reported As: CHATS Region V/Hospital Alert Tracking System

Data Source: MIEMS

Calculation Comments: Yellow Alert + Red Alert + Reroute

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SOLUTIONDMAIC: ANALYZE PHASE

During the analyze phase The ED Director met with several ED charge Nurses, ED Assistant Nurse Managers and all of the Administrative Supervisors. As a team, they drilled down to identify the root causes of the problem . The data collection sheet (single case bore) used allowed the team to collect as much data as possible and identify the causes. We then used a Pareto chart to help us analyze the frequency of the problems, and allow the team to focus on the most significant. We then utilized the 80/20 rule; in that 20% of the sources of defect are causing 80% of the problem.The two causes identified were 1. High volume and 2. No inpatient beds (Boarders in the ED). The Administrative Supervisors were broken down into two groups to tackle the causes.

First group- Focused on working with ED Charge Nurses and helping them identify when the department was getting overwhelmed. They worked on volume vs. acuity, staffing in ED, assignment of more experienced nurses over less experienced nurses 24/7. Communication with staff and Administrative supervisors with specific needs for the department. Information was reviewed during every shift and our monthly ED charge nurse meetings.

Second group- Reviewed the current Surge Policy for the Hospital and made recommendations on changes that will assist with Throughput and patient safety. They also focused on working with in-patient charge nurses on Surge policy and NEDOCS. Policy and review of NEDOCS was reviewed on every shift 24/7 along with the importance of communicating with the Administrative supervisors.

The ED Director worked with Administration and the Chief Nursing Officer to hire more travelers and review Nurse: Patient ratios. The possibility of implementing on-call into the Emergency Department was discussed with Administration and ED management, but was put on hold until budget was reviewed.

# Problem Root Cause Standard People

1. High Volume EMS and/or walk-ins are arriving simultaneously through the front door X

2. No inpatient beds (Boarders) No available inpatient beds and Staffing and/or census X X

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DMAIC: IMPROVE PHASECountermeasure How Responsibility Implementation Date

Implement on call process for ED Staff

1) Collaborate with CNO and Assistant Nurse Managers of ED regarding proposal

Director of ED, Manger of ED July 2017

2) Finalize proposal with staff to get “buy in”

Director of ED, Manger of ED July 2017

3) Implement and monitor for effectiveness

Director of ED, Manger of ED July 2017

Decrease nurse patient ratios—Charge Nurse not to take patients

1) CNO and Executive Director of Nursing to establish ratios

CNO/Executive Director of Nursing July 2017

2) Travelers and FTEs were added as additional staff

CNO/Executive Director of Nursing July 2017

3) Implement and monitor effectiveness of new ratios

Director of Nursing Administration July 2017

MEASUREABLE OUTCOMESOnce the action plan was implemented, we captured the progression on a graph. The graph captured the number of hours the ED was diversion monthly, our target goal, best competitor, and world class. We continue to meet world class. October 2017 Data was 17.23 hours on Diversion.The team also decided to look at the financial impact of going on Diversion. Based on the formula of the average level charged in our emergency department plus the average number of patients seen on an hourly bases; we calculated how much money would be loss if we averaged four hours of diversion on a daily bases. Total potential financial impact was $255,816.80 in a four month period (July-October) There was only a loss of $1,236.00 in a four month period, saving the hospital a total of $254,580.80 dollars.

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SUSTAINABILITYDMAIC: CONTROL PHASE

The team determined that the teams will stay intact and that the process should be reviewed every quarter or sooner as needed. The ED Manager and Director will continue to collect the data and evaluate the need for reevaluation. The success of this project will be shared at the Patient Experience Council as a best practice to improve the ED performance of our other acute hospital SGMC.)Contingency Plan1. Share the data collection process with ED leadership.2. Regular review of patterns of variances from established process at Administrative Supervisor Staff Meetings3. Daily coordination of established process between ED, CN and Admin Supervisor; resolve variances as they occur.

Impact1. Quality and Safety: EMS not being diverted to other hospitals that are farther and at times out of their counties, patients can maintain continuity of care with their own Private Physicians that have privileges at WAH2. Patient Experience: patients are not being diverted away from their community hospital 3. People: community and EMS are satisfied that they are coming to their designated hospital4. Finance: Hospital not losing potential admissionsCountermeasures:

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– Increase efficiency in throughput in the Emergency Department to decrease the number of hours having to go on Diversion in the ED

ROLE OF COLLABORATION AND LEADERSHIPAt AHC Senior leaders create, encourage, and maintain a focus on innovation by requiring performance improvement projects and continuous improvement to meet/exceed performance metrics.

These innovative ideas and tools which result from these improvement projects are shared with departments at the entity level through performance improvement Councils and shared throughout AHC at system Councils. Leadership representation from each entity at system Councils enable these best practice opportunities to be deployed throughout the organization. Adventist HealthCare has a culture of unit based and interdepartmental performance improvement, with nearly 250 DMAIC projects.

• R. Melendez: process owner; accountability• Administrative Supervisor's: team leader; coordinates logistics and processes• Cameron, Elsy, Keli: education, process improvement and implementation• Administrative Supervisor’s: data collection and analysis• ED CN, ED MD and Admin Supervisors: daily process implementation

INNOVATIONWhat makes this solution innovative is that we took a tool that was developed by someone else (NEDOC-NEW MEXICO UNIV.) and made it fit our needs at Washington Adventist Hospital; and as a result helped improve the care and services we provide. The use of the DMAIC process in conjunction with the use of the NEDOCS and the community partnership we formed with EMS allowed us not only to meet, but exceed our goals.LEAN SIX SIGMA: DMAIC Adventist HealthCare uses the DMAIC process as a data-driven strategy for continuously improving processes and driving innovation for optimal performance within our six Pillars of Excellence (POE). Findings from entity Performance Reviews are shared at entity President’s Councils where Senior Leaders bring together work groups and develop action plans that improve performance. Using the DMAIC PI process, teams incorporate the skills, abilities and knowledge of employees to work together to accomplish system priorities. Project teams consist of individuals at the departmental level and cross-functional teams at the entity or system level. During the Analyze and Improve phases, teams research innovative best practice countermeasures that can be implemented to drive breakthrough change. These innovative ideas are shared with departments at the entity level through PI Councils and shared throughout AHC at system Councils. Leadership representation from each entity at system Councils enable these best practice opportunities to be deployed throughout the organization.

As AHC has progressed on its journey to performance excellence, leaders identified the opportunity to include key suppliers, partners, and collaborators in DMAIC projects to maximize improvement potential.

INNOVATIONAHC defines innovation as process improvement and recognizes three types of innovation: staff-driven,

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innovation as part of the process improvement process, and leadership innovation—ideas/best practices identified through environmental scanning.

POE and aligned goals create an environment for innovation and intelligent risk taking by enabling departments to make data-driven decisions.

CULTURE OF SAFETYOur DMIAC impacted the culture of safety throughout the entire entity. The Surge Policy is the only policy that every unit leader both clinical and non-clinical assisted in writing together as a team. The leaders looked at the services they could provide the Emergency Department individually to affect patient care and the services provided.

PATIENT AND FAMILY INTEGRATION

At Adventist Healthcare our mission statement -“We extend God’s care through the ministry of physical, mental and spiritual healing”- serves as the guiding principle in our decision making and shapes our organization.At its core, our mission expresses who we are, why we exist, and our long-standing commitment to the health and healing of our communities. The dysfunctional processes in our ED and increased hours on diversion, were, in effect, separating patients from those elements which are core to their physical, mental, and spiritual healing; their local family, friends, and trusted healthcare professionals. Thus, the development of the solution was driven by the core commitment to our patients and family’s overall healing and the understanding that the climbing number of hours on diversion was increasing their levels of suffering and stress during a health crisis. A situation entirely antithetical to our mission.

RELATED TOOLS AND RESOURCESNARRATIVE: Evidence-Based research used to drive solutions, tools created as a result of the project.

Operational Excellence Team at AHC DMAIC Project Template available for all AHC employees to problem-solve Publically Reported data

SUMMARYNARRATIVE: Washington Adventist Hospital Deserves this award because we understood that inaction or maintaining the status quo for ED Diversions has a direct linkage to poor patient outcomes. Decreasing ED Diversions impacts the triple AIM by ensuring our patients are minimally affected by surges in volume and that we are available to care for our community and ED population effectively. Per a study of 995,379 ED visits that were admitted to 187 hospitals, patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death, 0.8% longer hospital length of stay, and 1% increased costs per admission. Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths, 6,200 hospital days, and $17 million in costs1. Therefore early identification of ED

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crowding through the efficient management of ED and house-wide throughput in a comprehensive multidisciplinary fashion is vital to the well-being of our community and organization.

1 Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L.-J., Han, W., … Asch, S. M. (2013). Effect of Emergency Department Crowding on Outcomes of Admitted Patients. Annals of Emergency Medicine, 61(6), 605–611.e6. http://doi.org/10.1016/j.annemergmed.2012.10.026

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