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Throughput plan includes department redesign
Patient flow office gets admission status up front
Before patients are admitted to Intermountain McKay-Dee Hospital, a patient flow nurse completes the first level of review for medical necessity and works with the admitting physician to determine the patient status.
"Our philosophy is that if we get the status right upfront, the downstream effect is minimized. If we get the patient status wrong, there's a lot of work that has to be done to correct it," says Charlotte Foy, MSN, RN, director of quality and case management at the 299-bed hospital.
The process was developed as part of the hospital's initiative to improve patient throughput by getting patients into the right type of bed under the right status and moving them along the continuum in an efficient and effective way,
"Our multidisciplinary team analyzed all aspects of the patient stay, beginning with how patients come into the hospital and looked at the most effective way to get patients in the right status once it was determined that they need to be placed in a bed. We recognized early on that this is a process that can't be owned by case management and social work alone," Foy adds.
The team created the new patient flow department, which is the main hub for all patients admitted into the facility except for those being admitted into labor and delivery and the psychiatric floor.
The office is staffed by patient flow nurses who are on duty 24 hours a day, seven days a week. Their only job is to assign beds and conduct medical necessity reviews. They are assisted during regular business hours by patient flow specialists who handle the clerical work.
"The patient flow nurses are like air traffic controllers. They use an electronic bed board that is color-coded and tracks patients from the time we first get an order for a patient to be admitted through discharge," Foy says.
When a patient is to be admitted, the patient flow office is alerted of the physicians order for admission and status. The patient flow nurse accesses the patient's medical record, conducts the first level of review for medical necessity, and works with the admitting physician to determine the patient status.
If the patient flow nurse doesn't agree with the order for level of care, he or she calls the physician and requests additional clinical information to support the level of care the physician ordered.
"They come to a consensus and the bed flow nurse lets the admissions clerk know the bed in which the patient will be placed," she says.
If the physician and nurse cannot agree on the level of care, the patient flow nurse admits the patient as ordered by the physician and refers the case to the physician advisor for review.
The hospital worked with a consulting firm on patient flow initiatives and in the process redesigned the case management model.
In the old model, staff called quality managers handled the case management and quality nurse tasks. They reported to the directors over their services, with the exception of the quality managers on the medical and surgical units, who reported to the case management director.
Now, all case managers and social workers report to a central manager. The case managers, who had been service-line based, became unit-based and are assigned to a number of beds in a unit depending on the severity of the patients.
Case managers and social workers cover the units and the emergency department Monday through Friday. Social workers work on weekends and holidays and are on call after business hours.
Before the patient flow project, the hospital did not have a case management documentation system. As part of the redesign, the department began using case management software that interfaces with the computers in the patient flow office and admitting and registration.
"We charted in the electronic medical records, but the system didn't allow us to pull reports. Now we have software that we can use to document everything we do, track trends, and conduct quality reviews," she says.
As the patient is admitted, the electronic registration system interfaces with the case management and social work system and triggers an activity work list for the social workers and case managers on that unit. The work list identifies various tasks ranging from insurance reviews to discharge planning.
Each patient is assigned a social worker and a case manager who work as a team.
"The social workers and case managers each have unique roles and middle ground where they can fluctuate back and forth depending on the needs of the patients and the needs of the unit," Foy says.
For instance, the social worker typically handles all psychosocial assessments while the case manager is the team member in charge of utilization review and regulatory issues. They both share discharge planning depending on the type and needs of the patient.
On admission, patients and family members complete a history form, which the nurse reviews and alerts social workers if there are discharge needs. Social workers conduct an initial screen within 24 hours of admission, assessing psychosocial and discharge needs.
The case managers look at all admissions each day and review the admissions status determined by the patient flow nurse. Patients with outpatient status who are receiving observation services are reviewed every day by the case manager.
"Our goal is to get patients in outpatient status either discharged appropriately or admitted as an inpatient within 24 hours if their condition warrants the change," Foy says.
Every unit in the hospital has a daily care coordinating meeting attended by the bedside nurse, the charge nurse on the unit, the case manager, the social worker, and other members of the interdisciplinary team when appropriate. Hospitalists attend when they are treating patients on the unit.
The team looks at why the patient was admitted, his or her progress, what needs to be accomplished before discharge, and the patient's discharge needs, with team members taking responsibility to see that the patient's needs are met.
Each patient room has a white board on which the team writes the goals the patient needs to meet before discharge and a tentative discharge day.
Within 24 hours after a patient is admitted, the bedside nurses and the rest of the team select an anticipated discharge date, enter it into the medical record and monitor it.
During the admission process, the staff talk to patients and their family members about who will transport the patient home, what kind of help they will need, and determine if they have transportation.
All the case managers and social workers attend weekly clinical high-risk meetings to discuss patients who are exceeding their expected length of stay, those whose cost of care has reached a high level, and those who have roadblocks to discharge.
The meeting is attended by representatives from insurance verification and the eligibility office.
The case management software system triggers patients who need to be discussed in the meeting. The case managers fill in additional information that helps the team determine the best steps to take.
"It's a great opportunity for the entire staff to meet and solve problems," Foy says.
For instance, if there is a patient on the surgical floor who is not progressing and who is fearful of going home, the psychiatric case manager may suggest a psychiatric evaluation or that the patient be discharged to a particular skilled nursing facility that has staff skilled in treating psychological problems.
It took about six months for the hospital to develop the patient flow initiatives, train staff, and switch to the new process.
"We had a great team working on it. We had daily huddles at noon every day and talked about what was going right and what was going wrong," Foy says.
To ensure that the patient flow process continues to run smoothly, the hospital's department directors meet once a week for a patient progression meeting.
The directors look at a variety of patient flow measures including how long it takes to transport patients to a bed once the bed is ready, how long it takes for the room to be cleaned once it's ready, and the length of time between when the discharge orders are signed and the patient is out the door.
"We've taken a team approach to our efforts to improve patient throughput. It wouldn't have been so successful if we just focused on case management and social work. Our conjoined effort has involved environmental services, the nursing staff, the clerical staff, and physicians. It's been a big change," Foy says.
[For more information, contact:
Charlotte Foy, MSN, RN, director of quality and case management at McKay-Dee Hospital, e-mail: Charlotte.Foy@imail.org.]