Operational Efficiency in Healthcare and Managing Capacity in Real-Time

Welcome to the Patient Flow podcast powered by TeleTracking. On today’s episode TeleTracking’s Susan McLaughlin meets Dr. Eric Brown. Physician Executive with Palmetto Health. Dr. Brown recently spoke at TeleCon and shared how his extensive emergency department background led to driving his passion for improved patient flow.

Dr. Eric Brown: Well, obviously as an emergency physician you're living the pain points of poor flow every day in every shift. Like so many health systems, particularly tertiary referral centers like our own, we really were just having increasing holds every year in our emergency department. Other markers, including poor patient satisfaction scores, high turnover rates and dissatisfaction between not only nurses, but also physicians. I obviously could do my best to work through that each day with each patient and continue to practice emergency medicine and focus on that, but I began to get into sort of quality and systems improvement, in general, in some other roles that I was taking on about 10 years into my career. It became sort of obvious to me that the single greatest challenge I think, not only to the emergency room but to the health system on a number of fronts, was poor patient throughput. That's when I sort of began considering what role I might play in trying to tackle this complex problem.

Susan: Dr. Brown, in your presentation you had mentioned engineering culture is like engineering processes. Can you talk about how you put those words into action?

Dr. Eric Brown: Right. So, again, the more I sort of got into complex change management and performance improvements and did a little bit of formal training but more just sort of leadership of various component projects, I recognized that no matter how many great ideas you bring to the table, no matter how hard you work, or no matter how well you do at assembling a passionate group of people to do that work with you, if you don't have a culture that supports that kind of change you're kind of set up for failure to start with. And I think that's no surprise to anybody who understands how to do this work. But my message yesterday was in fact that I think you have to be as active and deliberate in how you re-engineer your culture as you do the processes around really anything, but certainly something this complex. So given the fact that every corporate culture is different, there's certainly no one size fits all solution to that.

The first thing you have to do is kind of understand your culture and see where it's gotten in your way in the past, where it's supported efforts in the past, and that was sort of what I dove in on yesterday with that two day advance that we did to begin our revitalized effort around flow in the summer of '16. That was really about flushing out the culture and understanding what elements have gotten us some success in the past and what elements were barriers, and may in fact still be our barriers to really sustained improvement.

I learned a lot in that and subsequent those types of exercises, and you can never take your eye off that ball. You can never forget the fact that your culture is ever-changing, particularly in a healthcare setting where turnover is rampant. So you're always re-engineering your culture, because new people are always coming through the revolving door. The best systems in America have a playbook for culture, like they do a playbook for operations, like they do have a playbook for finance, right?

Susan: Right, right.

Dr. Eric Brown: Because they work deliberately on it and they have various tool sets to do so. But flow improvement and culture had to come together in a perfect mixture, if you will, to be successful.

Susan: Along the lines of culture and going with the theory that culture starts from the top, how did you engage your top executives to be just as engaged and passionate about this as you are?

Dr. Eric Brown: Yeah, so the conversation I had in the summer of '16 with our President was my first sort of putting my toe in the water to say really not if but when we really dive in on this revitalized flow improvement effort, it must have absolute commitment from the top down. And that would really be the Board of Directors to the C-suite on down. Then we can't just give it lip service, but we have to understand that this is a top priority for the organization. And our president, to his credit when we got together and talked about that, had lived it himself. He'd actually been the Chief Operating Officer on our major academic tertiary center for a number of years and had led through some of the initial efforts around flow improvement and then recognized again that we had tasted success, but that it had actually been fleeting. We hadn't achieved sustained improvement. And in fact in that summer of '16, that we were about the worst we've ever been in that state of affairs.

So getting his buy-in on that idea that we were going to do something different and that we were going to do it with an eye on sustainability and that we were going to have an unwavering commitment and would he be my partner in that in taking that to the Board and to the rest of the C-suite and making sure that we have that verbal commitment and that we continue to revisit it was part of the prerequisite of me saying I would sign on to do it. And he's been very good to his word in that regard. We've had regular check-ins. He's pushed me to work quicker and to work more efficiently on this and to accelerate the work. We've always maintained that it's a multi-year journey. You know, as Jake Poore said yesterday, when you stack it up it's a pretty unexciting list of small improvement projects that stack up to big, big improvements and we've got to continue to manage expectations at all levels of the organization that we're not going to flip it overnight. But our president has been that strong and consistent partner in all this, so I thank him for that support up front.

Susan: How did you determine what your system goals were. And you know, we're talking about incremental change, how did you go through a prioritization process?

Dr. Eric Brown: That was probably one of our early stumbling blocks, actually in that there was not a great deep dive on the right metrics for the early phase of our flow improvement work. In fact, what got handed to us were not the metrics that many of us would have chosen. What I mean by that is, we basically got big box goals, like reduce the average wait time for each emergency department patient, the average wait time for each PACU patient, and the median discharge time as our day one, year one goals. Where, in retrospect, and actually in the immediate period thereafter and now, certainly in retrospect that what we really needed to do is have some midterm process goals that allowed us to sort of map out whether we were taking our strategic plan and that driver diagram I displayed in my talk yesterday with our operational plan, and whether we were meeting operational milestones in the early phase, instead of picking those big box goals, which realistically we would not expect to budge in the early year or two. And we in fact haven't that much. So it's been again managing those expectations to say, "Yes, those are absolutely metrics which we must begin to improve in time,” but really the short to midterm goals are more things like process, things that measure the process. Many of the elements of the Teletracking best practices, use of ready to move, use of the pre-discharge order, different time intervals in those element processes. And those are the things that you need to be getting right, and ultimately then you will budge those top box metrics of actual hold.

Susan: One thing you had touched on yesterday was the realtime bed capacity and standardizing those processes.

Dr. Eric Brown: Yes.

Susan: Could you give some detail about that?

Dr. Eric Brown: Yes, so realtime demand capacity management, the RTDC system is sort of considered a best practice. It really starts with a simple element of setting up a daily bed huddle, which we really weren't doing in any formal fashion. And standing up those bed huddles in the fall of 2016 was our first foray into standard work. What we mean by that is, it's a scripted, choreographed daily endeavor that becomes standard operating procedure once you hard wire it. Representatives from each of the units come down with a certain tool they've filled out, which is the R sheet, standing for responsibility, and it describes exactly how many beds they have open, how many discharges they expect for the day. We match that up with how many bed requests exist in the moment or are anticipated to occur throughout the day for their unit and wherever there's a mismatch, we make a plan to make sure that they free up the number of beds to accept those patients that are coming their way.

Again, it's choreographed, scripted, and it's standard work. We've hardwired that now across all four of our campuses, so they're all singing off the same sheet of music. And from that, you get some really important data that comes off of that because every time you create those stretch plans, as we call it, to meet the demand capacity mismatch, the following day you review those stretch plans and say, "Did you get the discharge order from the physician? Did the durable medical equipment show up on time? Did the transport people show up on time? Et cetera." Wherever those patterns start to arise, those barriers, then those become what fills the pipeline for the next improvement work. So it's also a detection mechanism for the barriers to discharge.

Susan: In your presentation yesterday, you'd given sort of like a best-case scenario example of when all these things are clicking and working together. Could you give a brief summary of that example?

Dr. Eric Brown: As we talked about yesterday, about the power of storytelling in messaging, and how you continue to link kind of the mundane elements of flow improvement to your providers through a patient story and how you connect them to what really matters. Oftentimes patient stories are used to motivate, but we motivate by telling stories of failures, where we left somebody waiting too long, where there was an unfortunate quality issue, or God forbid some sort of poor outcome related to having to hold. What I chose to do is turn that on its side and actually tell a positive patient story.

So Mr. Smith's story was yes one that I made up out of my head, but it was a story of exactly what perfect patient flow, i.e., clinical excellence meeting operational excellence would look like for a patient who I just randomly called Mr. Smith. And so that story tells of his acute hospitalization, his post-acute care placement, of his time at home, and of the optimization of his health in the system that is patient-centric, it's fully enabled with elegant technologies like TeleTracking provides, and again it's married with clinical excellence to provide him with the best possible outcome. And that messaging in that story, particularly yesterday, has gained significant traction and I think is a good mechanism for many of us to use.

Susan: We've seen some pretty significant natural disasters recently, and you're in South Carolina so you're most definitely on the front lines of these types of situations. Most recently you dealt with Hurricane Florence. Can you talk a little bit about what preparing for a disaster like that is like and how the technology and having these strong processes in place, the culture in place helps you get ready for something like that?

Dr. Eric Brown: Sure. We've been in the pathway of a number of storms over the last couple of years, and had the good fortune of not having any major evacuations. In fact, in the recent hurricane, we were actually receiving patients from the coast where most of the brunt of the storm is obviously going to do the most damage. And so we really had to understand how to maximize our capacity in anticipation of receiving upwards of 100 patients in some early reports, what ended up being sort of somewhere in I think the 20s. But not really knowing exactly what's coming is actually part of the disaster preparedness methodology, right? Is that you prepare for the worst and you hope for the best. So our ability to, on a daily basis, really manage demand and capacity, is accelerated by that kind of potentially significant demand, particularly patients coming from hospitals where we don't normally take transfers, coming off the coast.

So what we did is, we really just sort of took our standard processes again that we developed around flow improvement, our playbook as we call it, which is our way of representing those processes that we use for daily operations and for surge conditions and embedding them in the emergency operations center. Not only the people who generally execute that playbook, but also the processes themselves and just overlaid it on the emergency operations plan. And in doing so, we really I think for the first time, actually, since we chartered our dedicated flow improvement team, had an ability to impact that disaster scenario, the preparedness as well as the execution when we began to take the transfers. And it was I think very gratifying for our team to be embedded in that.

Hope Stack, who is our Director of Patient Flow Operations, actually took on a logistics position as part of the emergency operations plan, and in doing so she was front and center in the emergency command center and was able to obviously pull in data from her flow team across our four hospitals and report that out, making sure that we were showing adherence to our standard work in preparation for those patients. So it worked out quite well.

It's been fantastic to be able to see TeleTracking's commitment and the solutions they continue to bring to market to fuel this work. I think we're all inspired by the net impact we can have in getting this right. We have to re-engineer healthcare. We have to re-engineer it to make for a better patient and provider experience and do so at a lower cost, and that is flow improvement 101. Getting that right will impact all those elements of the quadruple aim. And the fourth arm of the quadruple aim is of course joy at work. I've learned to never under-appreciate how much this is a bridge to resilience for our workforce, as well. In fact, it is in my mind equally as important to create a better workforce experience as it is to create a better patient experience. Because our workforce is clearly largely burned out, over-challenged ...

Susan: They work hard.

Dr. Eric Brown: Oh my gosh. And to the degree we can make their lives easier, keep them at the bedside longer, let them do what they signed on to do, and that is to be with patients and do patient care and make the logistics and tasks of their daily work easier and more streamlined, it's going to feed all the major agendas in healthcare transformations.

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