• Section 4: Using Technology to Improve Decision Making

    Nov 01, 2011

    Technology is helping healthcare leaders improve their decision-making ability at the bedside, in team meetings, and in the executive suite.

    Technology is becoming a critical component of provider efforts to improve quality and reduce costs. The technology is helping them track data/trends and identify better approaches for improved efficiency and patient care-thus, allowing healthcare organizations to better manage risk and improve overall value.

    This is Section 4 in the Fall 2011 Leadership report, Managing Business and Clinical Risks.

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    While every technology project is different, the two providers in this section share some common lessons learned.

    • Focusing not on the technology, but on how the technology will improve patient care, increase efficiency, and improve the work environment for staff
    • Overhauling workflow and processes before implementing
    • the technology
    • Designing technology around what staff and patients
    • really need-and possibly saving dollars by forgoing
    • bells and whistles
    • Involving physicians, nurses, and other staff in technology design and implementation
    • Using technology's data analysis and tracking ability for better decision making-at all levels of management
    • Determining and celebrating the ROI

    Case Study

    Improving Patient Flow and Nurse Staffing

    During a three-month period earlier this year, St. Anthony's Medical Center in suburban St. Louis treated 1,000 more patients in its emergency department (ED) than during the same period two years earlier. This was possible because the St. Louis hospital eradicated its long-standing problem of ambulance diversions.

    "Eliminating diversions for St. Anthony's is found money," says CFO John Skeans. "We were basically telling patients that we were closed for business."

    The ambulance diversion problem went away after St. Anthony's developed a software program that helps managers quickly redeploy nurses to where they are most needed, improving the flow of patients from the ED to inpatient units.

    That technology is one component of a complete overhaul of the hospital's nurse staffing system that resulted in a dramatic improvement in the hospital's financial position. "Where other hospitals and health systems have had layoffs and salary freezes, we have continued to have merit increases," says Sherry Nelson, St. Anthony's vice president of patient care services and CNO.

    On top of that, St. Anthony's will pay out "shared fruit" bonuses averaging $500 to each staff member because the hospital met its financial and patient experience goals for the fiscal year that ended June 30. It also paid out bonuses for the previous fiscal year.

    That is a far cry from 2009, when a cash flow crunch required St. Anthony's to drastically cut expenses. The hospital chose to address the financial problem by addressing its single biggest expense: nurse labor costs. Not wanting to inadvertently harm quality, the hospital identified creative solutions to use nursing resources more wisely.

    The result: St. Anthony's cut $25 million from its budget in 2009 and kept the hospital in the black- while improving the caliber of its nursing staff.

    Hiring to save money. "One of the things that is important to the bottom line is having the right staffing," says Nelson. That is why St. Anthony's staffing overhaul focused on reducing turnover among nurses, improving job satisfaction, and upgrading the level of nursing skill and experience.

    For starters, St. Anthony's increased nursing hires by 8 percent in 2009 so that it could stop relying on expensive travel nurses. Nelson also sought to recruit highly skilled registered nurses (RN) and limit the number of practical and vocational nurses on staff. At the same time, Nelson instituted consistent work schedules in each unit, which improved morale and reduced absences that, in the past, had required the use of contract nurses.


    Those practices helped St. Anthony's cut its travel nurse budget and achieve its ultimate goal of reducing turnover in the nursing ranks. The hospital's total voluntary RN turnover rate fell from 15 percent in FY10 to 13.5 percent in FY11.

    "Every time we lose a nurse, it costs the organization approximately $60,000, so reducing turnover is at the forefront of what we're working toward," says Nelson. "My goal is that the best nurses in St. Louis see their career endpoint at St. Anthony's Medical Center and that they would never want to work anywhere else."

    To build on the success to date, Nelson continues to introduce new initiatives to boost nurse satisfaction. Because it is difficult to recruit experienced nurses in the highly competitive St. Louis market, St. Anthony's must hire new graduates who have little real-world experience in the hospital setting. That is why the hospital created a nurse preceptor program in which experienced RNs receive bonuses for working one-on-one with new graduates to help them succeed on the job.

    Shifting resources. St. Anthony's also looked to technology-an internally developed software program called N Quality Staffing-to improve the allocation of nursing resources. Two hours into each shift, unit managers enter the unit's patient census into the staffing software, along with the number of nurses, unit secretaries, aides, and other staff members on duty. The software program compares this real-time data with the unit's standard patient-nurse ratio and gives a color-coded visual cue to automatically communicate staffing needs. The color orange means the unit is close to full capacity, and red means another nurse is needed.

    When nurse managers from all units gather for their daily huddles during each shift, they use this information to quickly reassign nurses to where they are needed most. Those staffing adjustments allow patients to move from the ED into an inpatient bed more quickly, freeing up ED beds and eliminating the need for ambulance diversions.

    "Improving throughput has increased revenue," says Skeans.

    Investing in a new software program during a financial crunch seemed daunting. By focusing on what nursing leaders really needed to manage staffing, St. Anthony's was able to develop a relatively simple system internally. "The commercial systems are more sophisticated, but this system lets nurse managers know visually if they have enough nursing staff to take more patients," says Nelson.

    Automating time and attendance. Additionally, St. Anthony's recently started using an automated system to standardize the capture of time and attendance information. Previously, nurse managers kept track manually of a nurse's work absences, lunch hours that were missed because of too much work, and other payday-important information. This led to inconsistencies in applying attendance policies, misunderstandings, and on occasion, inaccurate paychecks that required time-consuming paperwork to fix.

    Under the new system, the time clock that nurses use is equipped with a computer screen that captures all details of a nurse's time and attendance electronically. "You can swipe your badge and, for example, put in a code that says 'pay through lunch,'" says Nelson.

    This system improves attendance because nurses know what the official record of their work attendance says. "This consistent, standardized approach will decrease our call-ins from nurses asking for time off because everybody will know where they stand," says Nelson.

    Case Study

    Improving Clinical Care

    Standardization and improvement is also central to Sentara Healthcare's $237 million eCare system-which includes an electronic health record (EHR) and related technology. Six years into implementing eCare, Sentara leaders advise going full-out or staying home.

    "EHR rollout is not just the implementation of an application or a computer system; it's an entire redesign of the approach to care delivery," says Greg Hafer, RN, director of eCare operations. "It requires a commitment throughout the organization."

    The eCare system includes: 

    • Computerized physician order entry (CPOE)
    • Clinical decision support and standardized order sets and care plans
    • Online documentation
    • Medication administration with barcode scanning
    • Electronic capture of images, lab results, surgical summaries, and all other data
    • E-prescribing
    • Data sharing with state and national patient registries
    • A patient portal

    Sentara, a 10-hospital integrated system based in Norfolk, Va., took home the Davies Award from the Healthcare Information and Management Systems Society (HIMSS) last year in recognition of its successful eCare implementation and the improved patient care-and value-that stemmed from it.

    In addition to achieving the top status-Stage 7- in the HIMSS Analytics rating system for EHR adoption, a Sentara hospital has appeared on Hospital & Health Networks' "Most Wired" list in each of the past three years.

    Those accolades reflect Sentara's investment for the long haul.

    "Very early on, we framed this as the biggest capital project Sentara has ever undertaken, bigger than investments we've made in new facilities," says J. Miller Trimble, Sentara's director of information technology. "That was an attention-getter for the entire health system. When you discuss EHR implementation in those terms, staff generally buy into making it a success."

    After a two-year planning phase, Sentara implemented the eCare system at its first hospital in 2008-and its eighth hospital this year. (Two of the system's 10 hospitals were acquired this year.) This past spring, the health system completed installation of the EHR technology in all locations of the Sentara Medical Group, which employs about 400 physicians. In addition, more than 55,000 patients are now using Sentara's patient portal to communicate with physicians, schedule appointments, view test results, and request prescription refills.

    Planning thoroughly. Sentara made sure that eCare was a clinically-driven project by creating a Physician Advisory Group comprised of more than 25 community physicians. Members of the advisory group were hand-picked from a pool of physicians who had volunteered to serve.

    "You bring to the table the physicians who are known technology champions, but you also bring those who are potentially naysayers so that you can engage them early," says Hafer. He also recommends involving physicians who work in procedure-driven disciplines, such as surgery, because those areas present special challenges for the EHR.

    The physicians helped select the vendor, advised on software design, and served as "super users" during implementation to help other physicians and staff members learn the technology. They were paid an hourly rate for the time devoted to eCare, similar to the way a medical director is paid for administrative hours.

    During the design phase, members of the Physician Advisory Group spent about four hours a week on eCare. Currently, the group meets for about two hours a month to monitor eCare issues.

    Redesigning processes. Healthcare leaders need to recognize that overhauling work processes will present the biggest challenge to a successful EHR implementation-and offer the biggest benefit, says Trimble. Redesign processes before the new technology is installed, he advises.

    During the design phase and initial implementations, the eCare team included 100 clinical staff-nurses, pharmacists, radiology technicians, and others-who worked full time on the eCare initiative alongside 90 IT staff members.

    More than two years before eCare implementation at the first hospital, process improvement engineers were assigned to work with system-level process owners to redesign 18 major processes ranging from clinical communications to charge capture.

    Each of the redesign teams spent three months analyzing current processes, measuring performance, and identifying problems and opportunities. Using that information, team members designed ideal processes.

    For example, communication between clinical departments was identified as a process critical to both the quality and safety of patient care. Nursing departments and ancillary departments came together to define and develop key elements of patient information that were critical in the transition of patient care from one department to another.

    Team members then identified the changes that needed to occur to achieve these ideal processes and sorted them into four categories:

    • Changes that would occur automatically when the EHR was implemented
    • Changes that required action to exploit the EHR's full potential
    • Changes that had nothing to do with the EHR
    • Changes that would happen at a future point after EHR adoption

    A lesson learned: Sentara leaders assumed that the process owners would communicate and embed the new processes at the hospital, but this did not happen as envisioned, says Trimble. About six months before "go-live" at the first hospital, the process improvement engineers had to be engaged to work directly with more than 40 departments to help leaders and staff members understand their existing processes and adopt the needed improvements.

    This worked well in all but three departments- medical records, surgery, and endoscopy-where the process changes overwhelmed the staff members' ability to adapt, resulting in throughput problems when the EHR system was implemented.

    The problems were worked out during an optimization phase that is built into the EHR rollout at each Sentara facility. During this phase, members of the eCare optimization team work with clinical staff members to address implementation snags and ensure that the technology is being used-and achieving results-according to plan.

    Trimble says this optimization step is essential to generating and measuring the ROI for an EHR.

    Diving in. Sentara leaders learned another important lesson during its initial eCare launch: Go "big bang" with all EHR features rather than phasing them in over time.

    In that first hospital implementation, CPOE was not introduced immediately. So physicians and staff members experienced successive waves of major change.

    "We learned that there was a tremendous amount of resiliency to tolerate the chaos that ensues with major workflow changes," says Hafer. "But when you are constantly changing things, and there is no time in between for things to stabilize, people don't tolerate that as well."

    The big bang launch is now standard for Sentara eCare implementations. To prepare for such a highly disruptive event, each hospital performs competency and skill checks with staff members well before the technology goes live. For example, nursing staff demonstrate the process for medication administration with barcode scanning technology.

    "Probably the most important thing is to flood the units with enough support during the launch so that patient care is not delayed," says Hafer.

    Making better decisions. The eCare system provides information for better decision making at the bedside and all levels of management.

    In the paper-chart days, nurses had to flip through a patient's record, trying to assimilate data from the recent past to identify a trend that might help inform a treatment decision. Now when Hafer rounds through medical/surgical units, he sees nurses consulting trend lines on computer screens that display, for example, a patient's blood sugar levels over time to see how the current reading compares with the recent past.

    "We are seeing bedside staff starting to use data in a different manner," he says.

    Meanwhile, managers throughout the Sentara organization are using those same blood sugar level readings in different ways. The eCare data feed into Sentara's key performance indicator (KPI) dashboard, which reports hyperglycemic and hypoglycemic rates at the department, hospital, and enterprise level. The KPI dashboard also tracks two other process measures-the average duration of central line placement and the percentage of heart failure patients weighed daily- that can influence adverse events and length of stay.

    By having access to that data in near-real time, senior leaders, department/unit managers, and bedside staff can be in constant communication about expectations and how to remove barriers to achieving clinical standards and performance metrics. "We are seeing continual improvements in the numbers on the KPI dashboard," says Trimble.

    Improving business intelligence. In addition to clinical indicators, the dashboard tracks compliance with CPOE use (down to the physician level) and medication barcode scanning. And it allows managers to monitor patient volume and revenue statistics (including margin analysis and revenue by payer trends) over time, and benchmark them against expected values at a hospital.

    Three times each day, the dashboard updates patient census and occupancy rates by facility, unit, type of service, and financial class. More detailed and frequent information is captured from Sentara's EDs, including boarding hours, turnaround times for minor emergency care, arrival to triage, arrival to admission, boarding hours, and turnaround times for specific types of care.

    While some statistics are used for analysis and planning, others are used for immediate resource allocation. For example, every 15 minutes, the dashboard reports the average ED patient wait time, and when thresholds are exceeded, managers are alerted.

    The ability to use EHR data to see systemwide trends as they are developing offers opportunities that Sentara leaders did not foresee. When the H1N1 flu emerged in late 2009, for example, members of the infection control staff suggested that EHR data might be used to help hospitals plan and manage a surge in demand.

    The dashboard was changed to capture and report influenza-related diagnostic data, including upper respiratory diagnoses, flu-like symptoms, and viral syndromes, from hospital EDs and medical group practices every two hours. The information was presented graphically so that clinical staff members could see the trends from day to day and compare them with previous time periods (see the exhibit below).


    "Because we had the EHR and the KPI dashboard in place, it really took very little work to get the information posted and available to the key people who needed to see it," says Hafer.

    The dashboard helped leaders ensure that EDs and physician offices were appropriately staffed to handle surges of H1N1 patients. It also helped increase operational efficiency because staff members avoided stockpiling supplies; they could see the pace with which patient load was increasing and they could see how quickly they could get more supplies when they needed them.

    Calculating costs and benefits. In 2010, Sentara calculated $48.5 million in financial benefits-more than $10 million over budgeted benefits for the year. Redesigned clinical and administrative processes factor heavily in the ROI for the eCare system, says Trimble. (See the exhibit below.)


    Among the wins: Sentara hospitals are avoiding more than 10,000 potential medication errors every month since adopting the medication barcode scanning. Improved patient throughput reduced patient length of stay by more than 16,000 days in the first two years-and the average turnaround time from ED to inpatient status has been cut to 90 minutes. The medical records function now costs $3 million less per year, while claims denials have decreased by $500,000 annually.

    "It requires a fair amount of up-front work and discipline to create the business case and ROI structure for an EHR," says Trimble. "But if you apply the discipline to follow it and carry it out, it can certainly be done. We've been able to prove that."

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