Computer tool takes guessing out of redesign

Tool simulates alternative care models

Sentara Health System in Norfolk, VA, and a management consulting firm are removing the guesswork from patient-focused care redesign. No more wondering how many patients should be assigned to the cardiac care nurse, how many rooms a housekeeper can clean, or how many blood draws an aide can perform.

Sentara has found these answers through an innovative computer tool, called JMT BASIS designed by Atlanta-based Joule Management Technologies (JMT). The tool contains a database customized from Sentara’s clinical paths that can help evaluate alternative staffing models, analyze costs based on activities rather than hospital charges, and pinpoint wasteful processes and procedures.

"We can play ‘what if’ and see what the changes we make do to things like costs or workload," says Joyce Howe, RN, a member of the reinventing team at Sentara, a network of five hospitals, physician offices, and long-term care facilities, and a pioneer of patient-focused care redesign.

Howe says the tool could help Sentara slash its direct care labor budget by up to 30%.

The tool is in the early stages of testing, but Sentara is optimistic about its future uses. So far, Sentara has used the program successfully to validate its existing staffing model and budget, both of which have evolved through the hit-or-miss approach commonly used during PFC redesign. As expected, the program showed some units were overstaffed, some understaffed, and some on target.

Sentara is using the program to fine-tune its existing PFC model, which it plans to roll it out this spring on the cardiac step-down unit at Sentara Norfolk General Hospital in Norfolk, VA. After three months, when they’ve worked out the kinks, Sentara administrators plan to tackle the rest of the facilities.

PFC brought new IMS needs

Sentara hooked up with JMT following a search for an information management system that could handle the new needs of its redesigned organization. Sentara had decentralized such departments as phlebotomy and housekeeping, transferring those tasks to two new multiskilled positions: a service associate, and a care partner. The service associate’s duties include cleaning patient rooms, passing out meal trays, and transporting patients. The care partner’s duties include drawing blood, administering EKGs, bathing patients, and taking vital signs.

Sentara’s administrators, like others who have implemented PFC, discovered the redesign wrecked havoc on budgeting.

"It didn’t work anymore," Howe says. "We used to budget based on what we charged for the process, but that did not really reflect our true costs. It couldn’t take into account the changes we had made."

Under the old system, for example, the number of housekeeping staff was determined by the square footage of the hospital. Now that this task is incorporated into a new multiskilled position which is based on the unit, the old method no longer worked. Sentara needed a system that could take into account that rooms take longer to clean following a discharge or transfer than those that are empty or which house continuing patients.

In the same manner, the former budget model determined a phlebotomist’s workload by the number of blood draws. Now that task is performed by the care partner or an RN, who is also responsible for numerous other duties.

"We needed to know how to quantify these activities," Howe says. "We were just taking a [guess] at it."

Sentara reviewed numerous costing models, but could not find one that distinguished between costs, the amount the hospital spends and charges, which is the amount the hospital bills. JMT’s vice president, Mary Beth Edmond, RN, MBA, told Sentara her company’s tool could make that distinction.

The two organizations formed a project team of clinical managers, management engineers, finance representatives, and JMT staff and jointly developed the database, which is derived from Sentara’s clinical paths. The tool contains a database template that lists every activity required of every staff member who is involved with patient care across the continuum, including RNs, secretaries, housekeepers, and lab technicians.

The tool tracks how often the activity occurs, how long it lasts, and how many staff are needed to do it. (See sample patient summary, p. 55.)

Sentara has created more than 95 of these patient summaries for 12 inpatient and outpatient units, including medical-surgical and cardiac rehabilitation units, and electrophysiology and non-invasive labs.

The template JMT provides is based on best practices, which also makes it a valuable benchmarking tool, but it can be adjusted to reflect the unique practices at your hospital. You can add to it, delete items, or alter them. For example, the template lists charting by exception, a common best practice. If your facility has not adopted this practice, you can alter the template to reflect your own process, Edmond says.

By tracking the information, the database can be used to determine care delivery requirements and costs by patient type, unit, or operating center. (See tool, p. 56.)

"It forces you to look at every step in the process and question current practices," says Edmond, whose company leads the facility through installation, training, and implementation of the tool on a pilot unit, approximately a three-month process.

One of the first practices the tool forced Sentara to question was patient assessments. The tool showed that patient assessments account for 20% of total annual labor dollars. When staff scrutinized this task, they discovered assessments occurred with the same frequency and comprehensiveness across the continuum of care, regardless of acuity. The policy didn’t address the issue of patient conditons. As patients improve, they do not need to be given comprehensive assessments as frequently. Now, the hospital is considering changing the policy so that as patients’ conditions improve, they are given limited assessments throughout the day and comprehensive assessments every 24 hours.

This change in practice could result in a workload reduction of 8,000 hours and a savings of $150,000 annually on the step-down unit. It would also cut documentation time by 2,900 hours, resulting in a $54,000 savings, Howe says.

Sentara’s redesign team also used the program to analyze what tasks occurred when. They discovered that some tasks were scattered throughout the day unnecessarily. To increase staff efficiency and reduce the number of patient interruptions, Sentara bundled activities and reduced their frequency if deemed redundant. For example, care partners used to check IV-sites, catheters, and chest tubes, change dressings, and perform cough and debridement activities at different times of the day in four- or 12-hour intervals. Now, care partners perform all these activities twice a day at the same time, once during the day shift, once during the evening shift. The change resulted in a 50% reduction in labor hours. Howe says re-engineering of this type could result in an overall reduction of up to 30% in care delivery labor hours, Howe says.

Other processes the tool has brought into question include the transferring of patients to different care levels as their status changes.

"You can start seeing costs that have little or no value, Howe says. "If a patient’s only in the hospital for three or four days, it may be cheaper not to transfer them. There are hidden costs such as transfer orders and there are new caregivers who have to familiarize themselves with the patient."

Sentara’s application of the tool is still in its infancy, but administrators plan to use it across the continuum of care and in the disease management program, a burgeoning field in the health care industry.

"It’s still early, but we can see the potential," Howe says. "We can move staff around, protocols can change and we can see how that will affect us. We won’t have to guess anymore."

[Editor’s Note: For more information about Sentara’s redesign or JMT Basis, contact: Joyce Howe at Sentara Leigh Hospital, 830 Kempsville Road, 3A, Norfolk, VA 23502. Telephone: (757) 466-5227. Or Mary Beth Edmond at P.O. Box 724825, Atlanta, GA 31139-1825. Telephone: (770) 384-0700.]