All Entries Tagged With: "throughput"
The Lean Six Sigma process applied to case management
I recently spoke with a hospital customer who was trying to improve processes in the case management and utilization review (UR) departments at a large teaching hospital. The facility recently instituted 24/7 case management in the ED and was looking to create process improvement in a culture reluctant to change.
One of my favorite quotes is attributed to Albert Einstein who said, “Insanity is doing the same thing over and over again and expecting different results.” I fear hospitals, providers, and payers are applying business-as-usual methods to a vastly changing industry. Hospitals and physicians who are willing to explore process change and embrace what other industries have used successfully will prosper.
The Lean process
According to the Lean Enterprise Institute, “The core idea in Lean Six Sigma is to maximize customer value while minimizing waste.”
Sigma is a term used to represent levels of excellence or quality. Six Sigma seeks to achieve a ratio of 3.4 defects per one million opportunities. The process began in manufacturing as a defect-reduction effort and has spread to other industries, most notably air transportation. Airlines strive to achieve perfection because lives are at stake when an error is made.
The six process elements also known as DMAIC(T) include:
- D-define opportunity
- M-measure performance
- A-analyze opportunity
- I-improve performance
- C-control performance and optionally
- T-transfer best practice (to spread learning to other areas of an organization
A company or facility that follows the Lean principles focuses its core processes on continuously increasing customer value while producing no waste. These efforts result in processes that require less input (e.g., human, space, time, or financial) which equates to fewer defects and reduced cost.
Lean makes an organization more nimble, which allows it to react to changes in the market and customer preference. A Lean organization can create products and services with more variety, higher quality, and lower cost. It can also manage information and data used to generate services more efficiently because the information is simpler and more accurate.
Key concepts
Two key concepts in the Lean method are customers and waste. To make process change you must be able to identify and quantify these concepts. I can immediately think of examples of waste in hospital processes.
Hospital errors typically occur due to the vast number of processes required to complete a task. Simple things like when a patient uses an expired insurance ID can result in case managers sending clinical information to a payer who no longer covers the individual. The time lost while sorting out the mistake can cost the hospital a day’s reimbursement.
Then I thought about the medical record. The process of several different individuals and departments documenting in the patient record is open to significant error. I can recall the frustration experienced when the chart itself disappeared.
The customer
It was a challenge to identify and quantify the case management customer.
My initial thought was clear–the patient is the customer. Then I spoke with colleagues who said the physician is a potential customer. Without physicians and other providers who admit patients and refer them to outpatient services, there would be no patient to serve. Then it occurred to me that perhaps the customer is the insurance company or third-party payer because they pay for the services consumed.
It is easy to see how many customers case managers serve. A case manager who makes arrangements for post discharge care at a SNF may say the rehabilitation facility with an available bed is the customer. The ambulance available to transport the patient to the post discharge facility is also a potential customer.
Clearly, case managers serve multiple entities. To begin successful process improvement in case management, how do we identify the customer? What are your thoughts?
Download an admission/readmission assessment form
Karen Zander RN, MS, CMAC, FAAN principal and co-owner of The Center for Case Management in Wellesley, MA was kind enough to share an admission/readmission assessment form in the March issue of Case Management Monthly.
The form is designed to help assess a patient’s risks, barriers to discharge, and potential for readmission.
Download the full admission assessment form, with the readmissions addendum, here.
Sample transfer agreement
The January issue of Case Management Monthly includes an article about the importance of reciprocal transfer agreements.
Sherri Sochaski RN, BAS, director of case management at JFK Medical Center (JFKMC) in Edison, NJ was kind enough to provide a sample transfer agreement form from her facility. It is good parctice for facilities like (JFKMC), who accept patients for a more advanced level of care, to have a reciprocal transfer agreement policy. Reciprocal transfer agreements ensure the accepting facility can return a patient after specialized care is no longer necessary.
Identifying emergency department regulars can improve throughput
It would be safe to say that every emergency department (ED) sees a fair share of “frequent fliers” or those patients who seem to use the ED as an alternative to other healthcare resources in the community. Knowing “the players” or the clientele of the ED can help an ED case manager address issues that affect throughput.
In the past year, we at University Hospital, Upstate Medical Center in Syracuse, NY have put together a pilot program, patterned after programs we have seen in other hospitals. The hospital generated a list of frequent fliers in the ED during the previous six month period. We identified a group of patients who not only frequent the ED but also have primary care providers within the same hospital system. We used a team approach involving case managers and social workers in the outpatient setting, to address any barriers in the patients’ lives that may cause him to use the emergency department rather than the primary care office.
The expectation was that a social worker or case manager would see the patient each time one of theses patients presented to the ED or the outpatient setting. The social worker would document the reasons for the visit as well as any interventions in a shared file in the computer. We were all able to access that information daily, and keep tabs on the progress of each patient.
The goal is not to keep patients from emergency care. Sometimes those patients presented to the ED with legitimate emergencies, but often times a different setting would have been more appropriate. In the first six months we were able to decrease the number of ED visits in all the identified patients, and we saw an increase in the number of attended visits with their primary care providers. When the hospital generated list of frequent fliers in the next six month period, over half of the original patients were no longer on the list.
I believe that the ED case manager is a crucial part of the throughput process, and knowing the clientele can only enhance the productivity and efficiency in the ED.
What do hospital case managers do, anyway?
This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.
Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.
Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.
Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.
It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.
At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.
Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?
And one more important question: Do your physicians really know what case management is?
Optimizing patient flow to protect against the RAC
Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.
According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.
“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.
In the April 27th HCPro audioconference, Optimize Patient Flow Through Case Management: Maintain Revenue Integrity and Joint Commission Compliance, Cooke, along with patient flow experts Derenda S. Pete, RN, MBA, and Brooke Wollenberg McDonnell, MBA will discuss how Hospital of the University of Pennsylvania created 25 virtual beds and have created a system that not only keeps them RAC ready, but has allowed them to gain, on average, four hours on each discharge. The audioconference will also offer strategies for dealing with inappropriate admits, information on how to manage the uninsured and underinsured, tips on how to collect, analyze, and distill data to improve outcomes, and suggestions on how to communicate with physicians on appropriate admission criteria.
Audio update: Managing LOS
As pay for performance and Recovery Audit Contractor investigations gain a greater bearing on the amount and expediency of reimbursement, managing length of stay (LOS) has become even more crucial for case managers. While responsibilities of case managers expand, an important measure of success continues to be managing LOS.
Many case management departments look at meeting a target number of days a patient stays at a facility, however, evidence has shown this may not yield the best outcomes when looking to manage and improve LOS. Inova Health System in northern VA, has had immediate and sustained success in reducing LOS through targeting clinical milestones. Its focus has been on improvement of the patient’s condition and minimization of avoidable complications, resulting in improved quality of care and a proven reduction in LOS.
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What is the main role of the ED case manager?
Hi. My name is Peter Moran and I have been asked to do a monthly blog on emergency department case management. I am currently employed as a ED nurse case manager at Massachusetts General Hospital in Boston and have been in my current position for the past 7 1/2 years. My hope is to allow an avenue for people to pose questions regarding ED case management and share my insights with others as well as gain insight I can incorporate in my daily practice.
I recently received the following inquiry:
What should the main role of the ED RN case manager be? If the hospital you work in does not have a UR team, and the majority of the admissions come through the ED, should the ED CM be solely focused on UR and making sure admissions meet criteria? Just curious of what feedback I will receive.
Thanks, Shannon
Challenges for case managers in discharge planning
Discharge planning is a constant state of mind for our case management team. We continually strive to create a plan that is safe and comprehensive.
Discharge planning is also a major focus of accrediting agencies including both The Joint Commission (formerly JCAHO) and the Centers for Medicare & Medicaid Services (CMS). Our case management team has found that creating a safe discharge plan and initiating a thorough multidisciplinary assessment (including functional, psychological, and cognitive) within the first twenty-four hours has been a challenge. The challenge in safe discharge planning is usually the coordination of critical communication of all team members.
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