A Change in Culture Leads to Improvements in Throughput

Heather: So my name's Heather Beauford. I work at Washington Regional Medical Center, that's located in Northwest Arkansas. I serve as the Operations Manager, primarily work out of the Emergency Department, but I have been involved in TeleTracking since it started at Washington Regional about three years ago. So I do a lot of reports and data collection, and bring that back to the throughput committee to provide transparency for all of the departments on where we stand on our data and metrics and where to improve.

So around 2017 we really had struggled with some patient throughput, and so as a whole team starting at the top, Mister Shackelford, our CEO, he is wonderful. He is truly committed to improving the community and the patients and throughput. And we have a great team that follows Meredith Green, our CNO, Rebecca Kelly, our Assistant CNO. They are involved in patient throughput every day. We have daily leadership huddles, and they're right there in the room listening to the data that's provided. So they are very much involved.

A couple of opportunities that we had found along the way were our discharges, they were not occurring early in the morning like we had hoped. So we reviewed TeleTracking best practice guidelines, and we try to follow those standards to the best of our abilities. So we discovered that a lot of our patients weren't going home until mid to late afternoon. So that was one of our key focuses moving forward. Another area that we identified as an area for opportunity was understanding of the why behind TeleTracking. And so we had to figure out exactly what our goals were, where we wanted to start and how we wanted to chip away at this problem of patient throughput.

So what we did is we established a team that consisted of key stakeholders, department directors, CNO, Assistant CNO, we have a patient access team, the emergency department, and we created daily leadership huddles. So within those, each area has certain key metrics that they have to bring every day to report. So these are items such as length of stay, pending discharge compliance, things like that, that would be obstacles for patient discharges. And then we talk about ways to improve those. So we have a smaller leadership team that meets at 8:45 every morning. We discuss any obstacles, and then from there we have a larger bed control meeting that meets at 9:15, and that consists of not only those key stakeholders involved in the first one, but management teams, case management, environmental services, and a few more key players that contribute to the overall patient throughput on a daily basis.

Susan: Heather, as you're speaking about these groups, do you have an overarching patient flow governance council?

So we have patient throughput committee meetings and so those typically take place about once a month, depending on scheduling. And so that is where we identify what our obstacles are and what we want to work on. My goal coming here is to really work on EVS because we know that that's a common problem for us right now, within our organization. And so it's through pulling this, all these daily metrics and data through all the reporting that we know what our problems are and where we need to improve.

Heather: So we realize that a couple of areas that we really needed to improve upon was our staffing matrix, with both housekeeping and transporters. So what we did is we ran some standardized reports to figure out what time of day our patients were going home. And so from that we compare that with the number of housekeepers that we had here during those hours of the day. And what we found was that there wasn't an alignment in the staffing matrix versus the time the beds went dirty. So we had to do some readjusting of our hours of the day with our EVS team, and also with our transport staffing, in order to meet the needs of the organization.

With transporters, what we've found is there was both a need in the morning to do early morning discharges and early morning testing, but transporters went home 5:00 PM, and then there was no one to take up the ER patients in the afternoon to their rooms. So whenever we did the staffing matrix there, we realized that the transport hours were good, we just needed more transporters, and so we were able to identify a need for additional staffing based upon some of the reports that we ran.

I love these and these are the good slides, I think, where you have all of your metrics coming in. Was it after that success slide, if I remember?

Heather: I'm not sure. So what we were able to notice was that as patients were discharged early in the morning, our goal being 25% by 11:00 AM, that even as we gained a percentage or two that accounted to three or four beds being discharged, and that made a huge difference. And the result of that is we ended up decreasing our left without being seen rate from the ER in 2017 to 7.5% down. And this year, I'm happy to say that so far, for 2019, we've been less than 1% for the entire year. So we've made tremendous strides in patient throughput. We've made many accomplishments through using TeleTracking and best practices in addition to the left without being seen rate, we've significantly reduced our diversion hours.

We have increased our... No, we have decreased our ED length of stay and the amount of time it takes to get patients moved to inpatient rooms, we have increased our pending discharge compliance. And that's primarily, that goes back to educating the staff. So we realize that when TeleTracking was rolled out three years ago that there was some gaps in education. And so what we did is we've tried to capture all the new hires as they come in. And then, that's a lot of information to get an orientation, so I meet again with all the new nurses a couple of weeks later, maybe even a month or two later, depending on how the calendar falls, and just kind of go into a little bit deeper of why do we use TeleTracking and here's how we use TeleTracking. So they're hearing it more than once, they're seeing it, and then we also refer them back to their preceptors to use it. And so I believe that overall understanding and buy-in has significantly increased since we rolled out in 2016.

Susan: So you have that in place for your new nurses. What are some other things you've done to sort of ingrain this all in the culture for existing employees?

Heather: So, okay. First of all, it's the expectation that nursing department directors educate their staff. Starting with the managers, their coordinators and the rest of their frontline staff, on the expectations and what the goals are. This is done originally upon hire, and then it's done at monthly staff meetings and anytime there's a process change in between. So they hear this education frequently and then the key stakeholders are also invited to the throughput meetings as reminders.

I think when you did your dry run, you shared with us that there are dashboards in your executive suite. Was that you that was telling us that? [inaudible 00:10:37] executives have access to some of the dashboards [inaudible 00:10:41] within the system? Maybe that wasn't you, I went through so many dry runs with people. I can't remember who was telling us that.

Heather: I don't know how many of ours have, I don't know if they do or not. Not that I know of. I mean they all have access to TeleTracking.

Do you send reports to them regularly or share information regularly? What information?

Heather: So right now I have a folder on the drive that anyone can access. It's just called the Throughput Drive. And so it kind of breaks it down by department, and so rather than sending emails and clogging up the system, it's just there so anyone could click on it at any time. And so then there's data and graphs that go through and explain it, but then the majority of information is provided in the throughput meetings. There is talk about sending it out through emails in the future, or printing it out for them, but that's not happened yet.

We do have the whiteboards on every unit, for transparency, and then we also have the larger boards in our patient access department, so our bed control and administrative teams down there can have a clear visualization of what's going on with every area.

Susan: And do you do your huddles, around the portal boards?

Heather: No, actually we do those upstairs in the CNO, Assistant CNO's office, right next to the board meetings. So when everyone filters in, there's a big space for everyone there.

Speaker 2:                    And are you looking at the portal boards in that meeting?

1. Beauford: We look at those in the big meeting. In the private meeting we have a separate little white board that we write on with a marker board. So...

                                    We also customized our, what's the name of that? I don't know the name of what it's called. Let's see...

Speaker 2:                    Something in the portal board?

Heather: The patient flow dashboard. Yeah. So we did customize the patient portal, the patient flow dashboard to meet the needs of our department, or our organization.

Speaker 2:                    And what do you look at specifically? You're going to show us in real time?

Heather: Yeah, I'm going to show you... So what we're looking at here is every day we get an overall idea of where we stand on our occupied physical beds. We get a percentage of our patients that are discharged before 11:00, before 2:00, and then after 2:00 PM, and then this is also the way that we look at any patients that are holding in our Emergency Department or any overflows in our Intensive Care Unit or PACU area that need to be moved. So those patients waiting on a bed elsewhere. And then we also just kind of look at the overall percentage of what each department is staffed at, and how many beds they have that are either not being used or blocked or that could be utilized in the event of an upcoming situation.

Speaker 2:                    Any initiatives that you're working on right now? I know you said that you'd need to focus on some EVS improvements. Anything outside of that?

Heather: Well, so, I will say that we've made tremendous improvements with our discharges before 11:00 AM. We're not to where we want to be, but we are making tremendous strides in the right direction. Going forward we want to continue working on our discharges, early morning, and we want to include discharge planning the day of admission, so going forward, we want to just be sure that that is something that's ingrained and continues to happen on a daily basis. Right now we're doing pretty well with that, but it would be good if we could iron out some of those details to make sure that that continues to happen.

                                    In addition to that, I believe we need to work on Environmental Services and getting their response times improved upon. Right now we had some recent turnover and so we need to to work on some improvement there.

Speaker 2:                    Do you outsource your EVS team?

Beauford: No, we don't.

Speaker 2:                    No, they're internal.

Beauford: They are, yes.

Speaker 2:                    Heather, what, out of all the things that you've been working on, what are some of the things you're most proud of? Which accomplishments?

1. Beauford: Well, I'm based out of the Emergency Department, and so I live that day in and day out so I know that the struggles and the efforts that have been put forth by the ED team and I'm incredibly proud of them and all the accomplishments. And we are a very busy emergency department. We see over 60,000 patients a year. We have 37 beds. So we go through the beds really quickly. And the fact that we've been less than 1% for the entire year is just phenomenal. And I would say that's definitely the thing that I'm most proud of.

                                    But overall, just the whole transition, the buy-in from the staff, the early morning discharges, the... Just the effort and the teamwork that everyone puts through is wonderful. And as an organization, we have support from the top and it's just great to know that you're supported and that there's somebody there. If you, if you need something, whether it's a shoulder to cry on or just help with something. If it's a busy day, it's not uncommon to call up directors of the different units and say, "I need you to help me with transport." And they push a patient upstairs just like anyone else. So when it comes down to it, we're all one big team.

Speaker 3:                    Looks good.

Speaker 2:                    Thank you.

Speaker 3:                    Perfect ending line.

Speaker 2:                    And we're all one big team.

Speaker 3:                    And we're out.