- With
20 to 29 open-heart cases performed on any given three consecutive
weekdays and with an average length of stay following surgery of
five days, demand increased for open-heart and transitional rehabilitation
unit beds.
- The
interventional caseload during a 48-hour period ranged from 14 to
19 cases. Skillful coordination was needed to maneuver patients
through the 20-bed post-intervention unit and to accommodate an
average length of stay of 2.8 days. The midnight cardiology census
ranged from 94 to 124 during the winter season. Provisions for patient
beds with telemetry monitoring and nurse staffing were required
to accommodate a midday peak of an additional 20 patients awaiting
emergency admission, post-procedure care, transfer from ICU, or
discharge from the hospital.
- The
cardiac catheterization laboratory and the emergency care center
reported several-hour delays between 11 a.m. and 4 p.m. when arranging
for cardiac admissions. Integrated case management observed that
attending physicians tended to utilize telemetry monitoring in an
inappropriate fashion, creating bottlenecks in the system. Vacant
nurse positions in the cardiology nursing units affected bed availability
on other units, particularly on the overflow unit, which was only
able to open 18 out of 28 beds.
- The
cardiology patient placement process is a multidepartment and multidisciplinary
effort that involves nursing, interventional cardiology, cardiac
operating room, patient placement, case management, the emergency
care center, and the medical staff. The process should be streamlined
to reduce confusion, eliminate rework, avoid delays, and promote
good customer service. Policies and procedures that delineate the
most appropriate care setting for the patient must support the process.
- The
cardiology leadership team identified the following opportunities
for improvement: ensure that sufficient telemetry monitoring beds
are available during the "winter season," eliminate the redundant
and triangular communications in making patient placement assignments
for the interventional patients, and revise the configuration of
the cardiology patient care units to allow for a more positive hospitalization
experience.
Administrative
Decision
The hospital embraces the philosophy of continuous quality improvement;
it defines quality as "meeting or exceeding the needs of our customers."
Therefore, it views product or service to be quality only if it meets
customer's needs or expectations. For the hospital, continuous quality
improvement is an attitude, which involves looking for errors to improve
the system or process (Sarasota Memorial Hospital, p. 32).
The Hospital
Performance Improvement Advisory Council oversees the continuous quality
improvement activities throughout the organization. The council viewed
the proposed Cardiology Patient Placement Quality Improvement Team
(QIT) as a service line initiative that involved multiple cardiology
areas, patient placement, and integrated care management, and the
vice president for patient care services endorsed the need for this
initiative. See Attachment A for the interdepartmental QIT team request.
After
the approval, I proceeded to organize the Cardiology Patient Placement
QIT in March 1999, and I served as the team leader while the patient
care director for the post-anesthesia care unit served as the facilitator.
Representatives from cardiology nursing units, the cardiac catheterization
laboratory, patient placement, quality improvement, and integrated
case management also served on the team. The team followed the four
phases of the organization's approach to quality improvement: (1)
identification, (2) analysis, (3) recommendation, and (4) follow-up
(Sarasota Memorial Hospital, p. 5-6).
Identification
The team identified and collected internal data sources that would
assist the team in identifying opportunities for improvement. The
team utilized two quality improvement tools: flow chart and systematic
sampling. The flow chart is a pictorial representation of all the
steps in a process (GOAL/QPC 1988, p. 4), and it was useful in our
review of the patient flow process for the hospital's two high-volume
cardiology patients: (1) coronary angioplasty/stent placement (interventional)
and (2) open-heart surgery (see attachments B and C).
Systematic
sampling is a data collection method designed to collect one or more
individual events or measurements selected from the output of a process
for purposes of identifying the characteristics and performance of
the whole (GOAL/QPC 1988, p. 87). The team compiled the midnight cardiology
census for January 1999 along with data for open-heart surgery, interventional,
and cardiac catheterization case activity. The collected information
revealed the catheterization lab and the operating room schedules
and their impact on unit census and occupancy rates. Other data samples
included a chart review of 15 medical and 15 surgical charts, which
revealed data on transfer patterns, avoidable days because of lack
of monitored beds, number of cardiac patient transfers from community
hospitals, and number of patients held in the catheterization laboratory
because of lack of available beds.
The team
used the collected data to define its problem statement: 95 percent
occupancy on 5TA (open-heart step-down), 78 percent occupancy on 7ET/CAC
(telemetry/cardiac acute care), and 88 percent occupancy on 8ET (cardiac
progressive/telemetry) caused bottlenecks for cardiac patients and
decreased satisfaction for all.
Analysis
I led the team in constructing a root-cause analysis, which is the
process of identifying basic or causal factors that underlie variations
in performance. A root cause is the most fundamental reason that a
problem has occurred-a situation where performance does not meet expectations
(JCAHO 1998, p. 61). The team utilized a cause-and-effect diagram
(also known as a fishbone diagram or Ishakawa diagram) to clearly
illustrate the various causes that affect a process by sorting out
and relating the causes. The major causes were summarized according
to the four Ms: (1) manpower, (2) machine, (3) methods, and (4) materials
(GOAL/QPC 1988, p. 24). Refer to Attachment D for the cause-and-effect
diagram.
The team
identified and analyzed the following root causes for dissatisfaction
with the cardiac patient placement process:
- Manpower:
inappropriate utilization of telemetry and cardiac critical care
beds and nursing shortage that requires increased attention to recruitment
and retention of staff and exploration of alternative staffing strategies.
- Machine:
insufficient monitored beds and aging monitor equipment.
- Methods:
cumbersome patient placement process that involves multiple steps;
increased open-heart volumes that necessitate an update and review
of the continuum of care; and new devices or changes in use of thrombolytics,
which can affect current patient care protocols, length of stay,
and physician practices.
- Materials:
current unit configuration that does not provide optimal environment
for cardiology patients, staff, and physicians.
Recommendations
The team focused on identifying the leverage points in
the process by attacking one deeply rooted cause. The team looked
to two primary ways to improve the process: critical paths and bottlenecks.
Critical path focuses on the time and sequence for a number of operations
or functions, while bottlenecks look to the points in a process that
limit the output of the process as a whole. Identifying leverage points
and thinking about what is best for the system can help overcome longstanding
barriers to improvement (Joiner 1994, p. 38-41). This approach helped
team members determine their priorities and enhance their customer
service focus for the cardiology patient placement process. Refer
to Attachment E for root-cause diagram and remedies.
The team
then identified all possible actions to eliminate the root causes
and developed an action plan. The action plan outlined critical key
steps for implementation as well as timelines. Members of the team
were assigned responsibilities for seeking buy-in/approval from all
affected departments and for implementing the action plan. I and team
representatives presented the recommendations to the Cardiovascular
Performance Improvement Committee. See Attachment F for action plan
and initial implementation steps.
Alternatives
I examined the two approaches to continuous quality improvement adopted
by the hospital: the Quality Improvement Team (QIT) and the Clinical
Process Improvement Team (CPIT). The QIT focuses on a systems problem,
is multidisciplinary, has a staff leader, does not always have physician
members, and implements recommendations and changes in policy or practice
(rules) on behalf of the hospital. The CPIT focuses on a specific
DRG or procedure, has a physician leader, has a heavy number of physician
members, is multidisciplinary, and makes recommendations to improve
clinical care, which are used on a voluntary basis (Sarasota Memorial
Hospital, p. 4). I opted for the QIT approach because the cardiac
patient placement issues were issues that affect service, outcome,
and cost.
Obstacles
The need for improvements to the cardiology patient placement process
was quite obvious. The effectiveness of proposed changes would be
dependent on having adequate telemetry monitoring system capabilities,
appropriate bed configurations, and sufficient staffing. First, access
to cardiovascular beds must be addressed by providing needed resources.
Second, the implementation and adherence to admission and discharge
guidelines and telemetry monitoring criteria are vital to the process.
Cardiologists, internists, and cardiac surgeons need to support policy
changes and to make adaptations in their practice. The cardiovascular
departments and patient care units, patient placement, and integrated
case management play a vital role in facilitating and implementing
key steps in the patient placement process. Third, staff communication
with patients and families regarding their plan of care influences
customer satisfaction. Patients desire to be involved in their care
decisions and to have the opportunity to ask questions and provide
input.
Results
The team reported on its accomplishments in February 2000 to both
the Performance Improvement Advisory Committee and the Quality Committee
of the board. Senior leaders and board members were pleased to see
the breadth of improvements made by the team. See Attachment G for
summary of the status of the action plans.
The team
focused on updating several protocols (or critical paths) in the cardiology
patient placement process:
- Direct
communication between cardiac acute care and the cardiac catheterization
laboratory was instituted to make bed assignments for post-intervention
patients and to eliminate multiple telephone calls to patient placement.
- Cardioversion
procedures were transferred to the cardiac catheterization laboratory,
so patients benefited from a "one-stop service" for both procedure
and recovery. This transfer eliminated use of the post-anesthesia
care unit and unnecessary admissions to the cardiology progressive
telemetry area. The change also resulted in better coordination
of the cardiology and anesthesiology schedules.
- Patient
placement and cardiac transport service developed a priority system
for patient transports and bed-assignment procedures.
- The
cardiology progressive telemetry units developed criteria and a
recertification process for patients on telemetry monitoring. This
protocol was effective in identifying patients who no longer need
monitoring, reducing inappropriate utilization and minimizing bottlenecks
in the system. ยท The admission and discharge criteria for all cardiovascular
patient care areas were updated to reflect current practices.
- A
decision tree was developed for the emergency care center to facilitate
more appropriate patient placement decisions.
- The
cardiac catheterization laboratory reduced recovery time in accordance
with practice standards and introduced new closure devices, such
as Angioseal, to enable patients to ambulate more quickly following
their procedure.
Bottlenecks
in the cardiology patient placement process were also remedied by
focusing attention on providing required resources:
- Reliable
telemetry monitoring equipment was installed on the cardiology overflow
unit.
- Open-heart
surgery step-down beds were expanded from 28 to 36 beds. Telemetry
capabilities were increased to follow suit.
- Three-bed
rooms were eliminated on all cardiovascular patient care units,
which eliminated the patient and family complaints regarding lack
of privacy.
- A
plan for private room utilization was designed and implemented during
summer months and will be continued as long as census permits.
Manpower
issues were addressed as well in order to plan for sufficient staffing
for the cardiovascular areas:
- Recruitment
initiatives for cardiology progressive nursing units were successful.
Unit leaders focused on orientation and mentoring new staff members,
which is a positive turnaround after a number of staff members opted
to transfer to the new cardiac catheterization holding area.
- The
cardiac intensive care unit and the open-heart recovery unit have
developed staffing resources through the critical care internship
program and hiring of experienced full-time, per diem, and traveler
nurses.
The team
also reviewed the two major drivers for the need to improve the cardiac
patient placement process as its six-month follow-up: high unit occupancy
rates and decreased satisfaction. The leadership group reviewed the
patient census patterns during the winter 2000 season and determined
if adjustments were needed for the following year. The cardiovascular
patient care areas experienced a lower census during the winter 2000
season because of fewer admissions and decreased length of stay. The
occupancy rate for the cardiac progressive/telemetry unit (8ET) decreased
from 88 percent to 78.8 percent, while the occupancy rate for cardiac
acute care/telemetry was 70 percent, compared to 78 percent the prior
year.
Open-heart
step-down had an occupancy rate of 95 percent in January 2000, but
with the opening of eight additional beds in mid-February, that occupancy
rate decreased to 83 percent, alleviating delays in patient transfers
from open-heart intensive care and allowing for better coordination
with transitional rehabilitation services. The overflow unit was open
from January through March and helped to facilitate admissions from
the catheterization laboratory and the emergency department. Delays
in accessing cardiovascular beds rarely occurred during the winter
season.
Patient
satisfaction with services in cardiology areas improved. Open-heart
patients rated their satisfaction between 89 percent and 91 percent;
cardiac catheterization patients, including cardioversion outpatients,
reported satisfaction of 92 percent; and patients in the cardiac progressive
telemetry unit rated their satisfaction between 85 percent and 90
percent. The patient care directors reported fewer complaints regarding
delays in admission. Physician satisfaction with cardiology services
averaged 4.25 (on the scale of 1 to 5), which was one of the highest
service ratings by the medical staff. Employee satisfaction with his
or her job for the entire hospital averaged 3.85 (on the scale of
1 to 5). The employees point to not having sufficient resources to
do their job as a major dissatisfier. The team believes that continued
attention to critical paths and bottlenecks will have a positive influence
on these satisfaction ratings.
Overall,
the Cardiology Patient Placement QIT proved to be a rapid systematic
approach to identifying and addressing numerous operational issues.
Collaboration of disciplines and services is essential for performance
improvement. The process has enabled the cardiology patient care units
to be more effective in patient placement transactions. Challenges
will continue with the growing influx of winter residents, technological
advances, changes in Medicare, and the evolution of managed care.
The cardiology patient placement is complex and will benefit from
continued interventions to improve the process.
References
GOAL/QPC.
1988. The Memory Jogger: A Pocket Guide of Tools for Continuous Improvement.
Methuen, MA: GOAL/QPC, p.9, 24, 87.
Joiner,
B.L. 1994. Fourth Generation Management: The New Business Consciousness.
New York: McGraw-Hill, pp. 38-41.
Joint
Commission on Accreditation of Healthcare Organizations. 1998. Sentinel
Events: Evaluating Cause and Planning Improvement. Oakbrook Terrace,
IL: JCAHO, p. 61.
Kasan,
N., and S. Shkrab. 1999. "How to Mobilize an Organization with Commitment,
not Cash." Nursing Management (December): 16.
Sarasota
Memorial Hospital, Quality Improvement Department. Quality Improvement
and Impact Care. Sarasota, FL: Sarasota Memorial Hospital, p. 32.
---.
Process Improvement: The Journey Begins. Sarasota, FL: Sarasota Memorial
Hospital, pp. 4, 5-6.
Margaret
L. Mortensen, FACHE, is the vice president of operations for St. Vincent's
Health System in Jacksonville, Florida. Mrs. Mortensen previously
served as the executive director of cardiovascular and radiology services
at Sarasota Memorial Hospital. Prior to that, she was senior vice
president at Onslow Memorial Hospital in Jacksonville, North Carolina,
and she served as the cardiology service line administrator at Vanderbilt
University Medical Center. Mrs. Mortensen holds a M. B. A. from James
Madison University in Harrisonburg, Virginia, and a M. S. in Nursing
from University of Pennsylvania. This case study represents a part
of Mrs. Mortensen's Fellow project. It was voted one of the best cases
studies in 2000.
Attachment
A: Interdepartmental Quality Improvement Team Request for Approval
Name
of Proposed Team: Cardiology Patient Placement
Date:
Name of person requesting team:
- Potential
problem or opportunity for improvement your team has identified:
a. Difficulties encountered during "winter season' in having sufficient
beds for patients in need of telemetry monitoring
b. Redundant and triangular communications in making patient placement
assignments for high-volume procedure patients
c. Negative impact of configuration of patient care units on hospitalization
experience for cardiology patients
- Impact
on Service, Outcome, and Cost (Attach additional page if needed.)
Service
- Patients
remain for prolonged periods of time in intensive care due to lack
of available telemetry beds
- Telemetry
patients are placed in cardiac acute beds starting a cycle of multiple
patient moves due to volume of post-Stent patients needing CAC bed
- Outpatients
undergoing cardioversion or TEE could be observed in a holding area
environment rather than an inpatient bed
- Patients
experience multiple transfers during hospitalization
- Physician
dissatisfaction with delays in transfers from outlying community
hospitals
- Numerous
patient complaints regarding requests for private room and concerns
about noise, activity level and poor aesthetics
Outcome
- Delays
in progression of patients held for prolonged stays in ICU environment
- Quality
of care for medical surgical patients in telemetry areas are not
coordinated well
- Care
of patients in overflow unit may be disrupted and not well coordinated
due to weekend closure
Cost
- Cost
of maintaining a telemetry patient in ICU environment
- Cost
of meeting care needs for non-cardiology telemetry patient on cardiac
telemetry unit
- Cost
of general overflow unit versus designated overflow beds for cardiac
versus medical-surgical
- Cost
of completing multiple transfers during patient admission
3. Are
you monitoring an indicator related to this problem/opportunity on
your Department's IMPACT CARE PLAN? Yes No
If yes, attach a copy of the indicator with data collected.
4. Attach
any other data related to this problem/opportunity
See enclosed summary of issues identified for patient placement retreat.
In addition,
cardiology directors are gathering the following data:
1.) average # of transfers/patient-review 15 medical and 15 surgical
patients
2.) # procedures by day-PTCA/Stent and OHS (January 1999)
3.) log of admissions/discharges/transfers on cardiology nursing units
4.) patient flow charts of high volume patients (PTCA/Stent and OHS)
5.) # avoidable days in ICU
6.) survey area hospitals regarding cardiology patient placement
5. Has
a process flow diagram been developed to flow the sequence of steps
in the identified process? Yes___ No___
If yes, please attach.
6. What
other department or areas are affected by this problem and thus may
be represented on the team?
Invasive Cardiology, Cardiology Patient Care Areas, Bed Control, Rehabilitation
Services
For
the following Attachments, please call (312) 424-9473. They will be
faxed to you.
Attachment
B: PTCA/Stent Patients
Attachment
C: Bed Flow
Attachment
D: Cause and Effect Diagram
Attachment
E: Root Cause Diagram
Attachment
F: Action Plan Status for Cardiology Patient Placement QIT
