Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Prework for D2D Workshop LWOT Problem Tool Quotes Surge Scenarios LWOT LWOT Problem? 1 The EXCEL® Tool 1 Quotes Surge Scenarios LWOT Purpose: Calculates Past Average LWOT% per Month. Plots Past LWOT% Vs. Patient Volume. LWOT Problem? Directions: 1 LWOT Problem? Macros must be enabled. First, click the "Clear Data" button to clear the default data. Then, input the month, monthly number of patients that Leave Without Treatment (LWOT), and the total number of patient visits including LWOT in the table below. Fin OUTPUT: Clear Data Month Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Analyze Data Historical Information LWOT# Total Patients LWOT% 710 8037 8.8% 1105 8154 13.6% 673 7761 8.7% 396 7177 5.5% 254 7284 3.5% 253 6956 3.6% 202 7012 2.9% 315 7351 4.3% 419 7523 5.6% 335 7531 4.4% 367 7480 4.9% 446 7802 5.7% 983 8837 11.1% 1103 7986 13.8% 1130 8557 13.2% 1341 8314 16.1% 1307 8284 15.8% 730 6977 10.5% 703 7027 10.0% 808 7356 11.0% 588 7431 7.9% 658 7740 8.5% 634 7622 8.3% 1742 8842 19.7% LWOT# Average per Month 717 Fit Performance R2 -30% LWOT% Patient# 9.1% 7710 Red if R2 < 35%. Queuing Prediction Curve of LWOT[7] 3000 25% 2500 20% 2000 LWOT# INPUT: 15% 1500 10% 1000 5% 500 2% 0 0 2000 4000 6000 Total Patients 8000 10000 12000 Minimum Volume Requirement Tool Volume ≥ Min? 2 Acuity Split Hourly Peaking The EXCEL® Tool 2 Purpose: To determine whether a facility has sufficient volume to support a separate Intake/Discharge area INPUT: Daily Planning Volume (Including LWOTS) 233 Acuity: Level 1 (f1) 0.03% Level 2 (f2) 8.28% Level 3 (f3) 68.73% Volume ≥ Min? Level 4 (f4) 20.53% 2 Level 5 (f5) Sum (must equal 100%): 2.18% 100% OUTPUT: Annual Planning Volume 85045 Peak Hourly Time of Day Multiplier ED Arrivals Peak Period (9am-9pm): 1.30 12.6 Acuity Split Hourly Peaking Arrivals/Hr to Intake/Discharge 22.8 ← In this cell, Green indicates that at least one Intake provider is required (several may actually be required). If the cell is Red, then volume is insufficient. NOTE: Assumed average length of stay in Intake = 15 min., average length of stay in Discharge = 7.5 min. D2D Care Process Tool Flow Chart A Care Process Acceptance Goals • With this tool, the user will be able to answer the question: “How would our current Emergency Department (ED) care process need to change to implement the Door to Doc (D2D) Care Process?” • This acceptance assessment is based on two exercises: a walkthrough and a flowchart comparison of current ED processes to the D2D Care Process. Door to Doc Care Process 3. Patient escorted to Intake Space (RN or Tech) 4. MSE/focused assessment, Orders & Documentation (RN and Physician) 5. ED Bed Required? No 6. Diagnostic Testing Required? 8. Medical Imaging B 9. Procedure/ Treatment Yes “Less Sick” Patients 7. Specimen Collection A Intake (ESI 3- 5*) No Patient Arrives 1. Quick Reg (PFS Rep) and Quick Look (RN) “Sicker” Patients 2. Sicker? (ESI 1 or 2) 10. Move patient to Results Waiting Area 13. Patient escorted to ED Bed *ESI-Emergency Severity Index 11. Review of Results 19. Patient to Discharge Room for Informed Discharge 12. Medical Decision Making 20. Patient to IP Unit/IP Holding Unit 14. MSE/Focused Assessment, Orders, Specimen Collection, Procedure and Documentation (RN, Tech, Physician) Full Registration & Co-Pay Collection (PFS Rep) Patient leaves the ED 21. Transfer to another facility 18. Patient Remains in ED Bed Yes Acute (ESI 1- 2*) A B No No 15. Testing 16. Treatment 17. Patient meets Results Waiting Criteria Yes B Your Current ED Process Flow To be sure you know how your current ED process operates, do a “Walk-Through” Tips for Your Walk-Through • Start with patient entry into the ED and end with the patient leaving the ED • Include two to three people, if possible, with each viewing the process through the eyes of a nurse and physician, patient and physician, etc. • Conduct walk-through at different times of the day, days of the week • Make a point of noting the paper trail of charts, lab reports, referrals, transfers, medications, etc along that accompany the process steps • At different steps ask the staff to tell you about the process step Questions to Ask • • • • Is this a busy or slow time? How long on average does it take to complete a process? Is the current process working well for patients and the staff? Is the staffing level the same 24/7? Use this information to construct a “high-level” flow diagram of the current process • Use ‘sticky notes” on a large surface in a group setting to identify and arrange the steps before drawing it on paper Patient Arrival Process Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change. Start with the first steps as the patient arrives at the ED. Check the box that best describes the magnitude of the change. Step Description Possible Changes Staff Affected 1a. Quick Registration -Patient Accounting system accommodation for ‘Quick Registration -Arrangements to complete registration later in care process -Patient Registration co-located with Quick Look Patient Registration or Business Representatives 1b. Quick Look -Eliminate triage -Co-location with Quick Registration Nursing staff, particularly Triage Staff 2. Sicker? -Adopt “quick look” methodology (such as Emergency Severity Index) for identifying sicker and less sick patients Nursing staff, particularly Triage Staff 3. Patient Escorted to Intake Space -Not all patients taken to an ED Bed Techs BIG Change Medium Change Small/No Change Caring for “Less Sick” Patients Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change. Continue with the process for “less sick” patients. Check the box that best describes the magnitude of the change. Step Description Possible Changes Staff Affected 4. MSE/focused assessment, orders and documentation -Jointly performed medical screening, rather than nursing and physician separate -Patient focused documentation (rather than separated by provider) -Eliminates mix of sicker and less sick patients increasing the number of patients that can be seen by a physician Physicians, Nurses, Techs 5. ED Bed Required? Physicians 6. Diagnostic Tests Required? -Handoff by physicians of patients who are determined to be “sicker” after medical screening exam n/a 7. Specimen Collected 8. Medical Imaging Performed -Less sick patients move to these areas as directed on their own -Less sick patients move to these areas as directed on their own Ancillary staff Ancillary staff 9. Procedure/Treatment Performed -Less sick patients move to these areas as directed on their own Ancillary staff n/a BIG Change Medium Change Small/No Change Caring for “Sicker” Patients Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change. Continue with the process for “sicker” patients. Check the box that best describes the magnitude of the change. Step Description 13. Patient Escorted to ED Bed 14a. MSE/focused assessment, orders, specimen collection, procedure and documentation 14b. Possible Changes Staff Affected n/a n/a Full Registration and Co-Pay Collection -Complete registration at bedside 15 Testing n/a Patient Registration or Business Representatives n/a 16 Treatment 17 Patient ok for results waiting? -Patients not requiring a bed moved out of acute bed to results waiting Physicians, Nurses, Techs 18. Patient Remains in ED Bed BIG Change Medium Change Small/No Change Decision Making and Leaving Review the flow diagram of your current process compared to the D2D process to identify the estimated scope of the change. Continue with the decision making process and leaving the ED. Check the box that best describes the magnitude of the change. Step 10. 11. 12 19. 20 21. Description Move Patient to Results Waiting Area Review Test Results Medical Decision Making Patient to Discharge Room for Informed Discharge Patient to IP Unit/IP Holding Transfer to another facility Possible Changes -Less sick patients don’t own a bed -May involve handoff from original caregiver -Utilize standardized approach for discharge and completion of registration and co-pays as needed -Separate location for discharge process -May involve handoff of care -Admitted patient care assumed by inpatient care providers n/a Staff Affected Physicians, Nurses, Techs Physicians, Nurses, Techs Physicians, Nurses, Patient Registration or Business Representatives Inpatient and ED nurses, physicians n/a BIG Change Medium Change Small/No Change Next Step • Review the results of the comparison of your current process with the D2D Care Process. • Now that you have identified the magnitude of the changes that will be required to implement D2D in your Emergency Department, the next step is to determine whether the critical success factors for acceptance of these changes are in place. Ready to • Proceed to the next tool: Change? Survey B Definitions: • Quick Registration: Registration clerks collects only the information needed to get the patient into the system (i.e. name, social security number, birth date) and COA signed • Quick Look: The nurse only needs to document the chief complaint, allergies and a set of vitals in some cases • Intake: Physician Medical Screening Exam including the H&P, review of systems, physical assessment medical history as well as the questions that nurses are required to ask including current medications, vital signs, domestic violence, immunizations, pain assessment and skin assessment • IPED: The area of the ED for patients that need a bed during their ED stay • OPED: The area of the ED for patients that don’t need a bed during their ED stay • LWOT: Patients who leave without treatment • ESI: Emergency Severity Index, an ENA triage tool to assign acuity of patients using minimal data Data Requirements Month January February March April May June July August September October November December Total number of visits including LWOTS ESI Level 1 % of patients at Level 1 ESI Level 2 % of patients at Level 2 ED Acuity ESI Level 3 Mix ESI Level 4 % of patients at Level 3 ESI Level 5 % of patients at Level 5 Ave Daily visits Number of Patients seen including LWOTS Admission Rate Number of Admissions/Number of visits Quick Look How long does it take to do Quick Registration and Quick Look (see definitions above) Intake Average time for a Medical Screening Exam/Nursing Assessment (see definitions above) OPED Discharge Average time it takes a provider for a discharge (or "across the hall" transfer order) from the OPED area Number of LWOTS % of patients at Level 4 Stats ED Average Times Length of Test/Treatment (TAT for tests and procedures) LOH(Adm it) Length of Hold (Time for decision to Admit to patient leaves the ED) Overall LOU Length of Use (Time from patient arrival to an ED room (IP or Intake) to decision to discharge, admit or transfer is made) Output Data Tracking (to be filled in with outputs from the Toolkit) Tool 3 Patient Arrivals per Hour Quick Look Intake/Discharge Results Waiting Peak Period (9am - 9pm): Off-Peak Period (9pm - 9am): Overall Daily Average: Tool 4 Area Quick Look Intake/Discharge - Results Waiting LOU - IPED LOH (Admit) - Inpatient Transitional Care Average Time (min.) Coefficient of Variation IPED Inpatient Transitional Care