By Mark Lane Welton, MD, MHCM, Chief of Staff, SHC, and the Harry A. Oberhelman, Jr, Professor & Chief of Colon & Rectal Surgery
The Surge of 2014 brought into clear focus a few truths. First, Stanford Health Care is in tremendous demand from patients, referring physicians and health care systems. Second, our care providers invariably rise to the challenge and continue to provide outstanding care even under challenging conditions. Third, the administration is teaming with physicians as never before to optimize our ability to deliver the care we all expect to provide to as many patients seeking our care as possible. Finally, we need to reassess our standard work, and look for efficiencies and opportunities that allow us to deliver more cost-effective, patient-centered care.
As a consequence of the tremendous new faculty recruits across the school, our improved focus on quality and patient-centered care and initial efforts to improve access and flow, demand has never been higher. Our growth in 2014 over 2013 has been noteworthy:
- 8% in the Emergency Department
- 6% in interventional case volume (OR, IR, cath lab, endoscopy),
- 10% in transfer center acceptances, and
- 3% in total inpatient days.
The total inpatient day increase is all the more impressive when considering that the multidisciplinary Patient Flow team, co-led by a team of doctors (Sam Wald, Neera Ahuja, Sam Shen), nurses (Wendy Foad and Gretchen Brown) and administration (Tim Morrison, Marlena Kane and Janet Rimicci) with sponsorship from Nancy Lee and James Hereford, shortened length of stay for patients in medicine services by nearly 24 hours compared with the same time last year. Kudos to this dedicated team for its vision, innovation and implementation.
The Winter Surge of 2014 created a "burning platform" for us to reassess how we care for inpatients, admit outpatients to our infusion centers and interventional suites and discharge patients from these care areas. If we are to continue to care for increasing numbers of patients in our existing physical plant, physicians need to partner with administration and care provider teams to improve communication with patients, their families and associated care facilities (SNF and regional hospitals). The "Crowding Team" created in December around the Winter Surge of 2014 is a perfect example of how we can nimbly put together a multidisciplinary team, impact the immediate "crisis" and then apply the lessons learned to "routine" patient care. We experimented with 23-hour stays in the ASC PACU, changing admission days for planned chemotherapy and discharging patients to local hotels if they weren't in need of an acute care facility, but "just live too far away" for everyone's comfort.
We learned that with a little change in workflow we could discharge patients before noon. By simply raising awareness of the crowding issue, residents and faculty were able to anticipate discharges and place the order the day before discharge. This is great for patient-centered care. It allows families to plan when they should leave to pick up their loved ones and when they should have mothers, brothers, sisters and cousins available to help with babies, children and parents. It also allows elderly people to leave for home earlier in the day so they aren't driving after dark.
This minor change in workflow, entering discharge orders the night before, allows nurses and support staff to prioritize activities. If a patient needs to see a stoma nurse, obtain an ultrasound, see physical therapy or have an echo prior to discharge, these activities can be prioritized, organized and coordinated so that the chance of an avoidable delay is minimized or eliminated. Without such orders and communication occurring the day before discharge, or even earlier, it is naïve to expect everything to be accomplished in time for the patient to be discharged early in the day. It simply won't happen.
I was told by one physician during our Winter Surge that I was just trying to make more money for the hospital and he wasn't going to compromise the care of his patients so the hospital could make money. The hospital does make money in patient care, as do the physicians. However, improving communication between care providers so that one patient doesn't wait hours in the emergency department (or tent, or hallway) for a bed, only to be admitted to a hallway bed because the care team hasn't organized the discharge of another patient isn't about the hospital or physicians making money. It's about eliminating unnecessary patient suffering for both the patient awaiting discharge and the patient trying to get out of the hallway. It's about operating on patients we said we were going to operate on and doing it within reasonable working hours.
Last year we were at 88 percent capacity and we had to cancel 18 cases during our Winter Surge. This year, we were at 91 percent capacity and we canceled zero cases. That's a big victory! However, we achieved this by not scheduling elective add-ons to the OR schedule, which means we weren't providing promised care to patients who needed our help. That is not insignificant. Personally, I have had over 20 operations performed on me. Mentally preparing for surgery is tough. When you don't operate on patients as planned, it throws off the patients and their support system, as well as the patient care team. It increases patient suffering unnecessarily, and we should be doing everything within our power to decrease patient suffering. One way to manage our high capacity is to eliminate avoidable delays in discharge.
This over-crowding problem is of our own making. The word is out. We provide outstanding care. This is a good problem. It leaves us with an opportunity to rethink our standard work. I don't see the "problem" going away. I see the Winter Surge of 2014 becoming our new normal. The Crowding Team is still meeting at least twice daily. During the crunch, we met up to six times per day. We are trying to "think of everything." Let us know where you see opportunities, successes and roadblocks that we don't see.
By: Mark Lane Welton, MD, MHCM, Chief of Staff, SHC, and the Harry A. Oberhelman, Jr, Professor & Chief of Colon & Rectal Surgery