Door to Doc (Text Version)

On September 27, 2010, Joseph Guarisco, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (4.47 MB).  

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Slide 1

AHRQ
Annual Conference

Bethesda, Maryland
September 26-29, 2010

Slide 2

Ochsner Medical Center

Image of Ochsner Medical Center

Slide 3

Door-to-Doc (D2D) Patient Safety Toolkit

Banner Health and Arizona State University
AHRQ Grant #: HS015921-01 

An image of the Door-to-Doc (D2D) Patient Safety Toolkit flowchart is shown.

Slide 4

Intersections

• Hurricane Katrina's crossroads

An image of the New Orleans area with a hurricane swell is shown.

Slide 5

Intersections

• Hurricane Katrina's crossroads

An image of the New Orleans Time Picayune newspaper with the headline "Clear Out or Else" is shown.

Slide 6

Intersections

• Hurricane Katrina's submerged crossroads

Two images of street signs on the South Louisiana Submerged Roads Program are shown.

Slide 7

An image of an article from the Times Picayune is shown. The title of the article is "Maryland is hungry for Louisiana crabs, but Louisiana can't deliver."

Slide 8

An image of an article from the Times Picayune is shown. The title of the article is "Crab-crazy Maryland finds itself a victim of BP's Gulf oil spill."
 

Slide 9

A graph comparing LWBS% between Post Katrina and Pre Katrina is shown.

Slide 10

A graph comparing the Wait Times between Post Katrina and Pre Katrina is shown.

Slide 11

An image of an article titled "Two Years Later, Every Day is Monday in New Orleans Emergency Departments." is shown.

Slide 12

Sign on a restaurant door titled "Why a Restaurant Customer Quits"

1% Die
3% Move Away
14% Unclean Dining Area
14% Bad Food
68% Indifferent Attitude About Service

Slide 13

NBC11.com

911 Call: Ignored Woman Dies On ER Floor

Chief Medical Officer Ousted In MLK Emergency Room Death Aftermath

An image of Edith Rodriguez is shown.

Slide 14

• ED Crowding
  • Output (admission delays)
  • Throughput (non-lean workflow)
  • Input (poorly engineered demand management)

An image of a cartoon is shown. The caption reads "Martha, I am not feeling too well. Maybe we should go over to the ER and get triaged!!"

Slide 15

Solve this problem

Slide 16

An image of a cartoon character thinking is shown.

Slide 17

• Cracking the code
  • Implement lean workflow
    • Lean registration
    • Lean triage
  • Create virtual capacity
    • processing protects the most precious resource...the bed
    • Rules based process
  • Match resources to demand
    • Queuing Theory
    • Grocery Store Math© for EDs

Slide 18

An image of a qTrack (design schematic) is shown.

Slide 19

An image of qTrack (overview) is shown.

Slide 20

An image of qTrack (workflow simple) is shown.

Slide 21

Door to Doctor 2010

A chart showing Door to Doctor 2010, Minutes vs Hours of the Day is shown.

Slide 22

System Door to Doctor

A chart showing System Door to Doctor (target 20 min) is shown.

Slide 23

System LWBS

A chart showing System LWBS (target 1%) is shown.

Slide 24

Door to Doc

Image of three different bar charts. Each chart shows the time span of March 2010 through August 2010. One chart is on LWBS, the second chart is on D2D (min); and the third chart is on Volume.

Slide 25

Cost Analysis of LWBS

• Net revenue (for real current LWBS payor mix)
  • Outpatient facility net revenue @ $300/visit discharge (90% of visits)
  • Inpatient facility net revenue @ $5,000/visit admission (10% of visits)
  • Professional provider net revenue @ $125/visit all (100% of visits)
• 1% LWBS @ 50,000 visits = 500 visits
• Lost opportunity net dollars for every 500 visits that LWBS
  • $135,000 facility outpatient revenue (450 pts x $300)
  • $250,000 facility inpatient revenue (50 pts x $5,000)
  • $62,500 professional revenue (500 pts x $125)
• Cost of 1% LWBS at 50,000 volume = $447,500

Slide 26

	Current YTD	Budget YTD	Prior Year	$ Budget Variance	% Budget Variance	$ Prior Variance	% Prior Variance
Emergency Medical Systems Nom
Inpatient Revenue	5,327,186	5,824,026	5,820,848	(496,860)	-8.53%	(493,662)	-8.48%
Outpatient Revenue	10,037,577	7,472,123	7,235,991	2,565,454	34.33%	2,801,586	38.72%
Total Gross Patient Revenue	15,364,763	13,296,169	13,056,839	2,068,594	15.56%	2,307,924	17.68%
Other Revenue	0	0	152	0	0.00%	(152)	-100,00%
Total Gross Revenue	15,364,763	13,296,169	13,056,991	2,068,594	15.56%	2,307,772	17.67%

Slide 27

• Requires a leap of faith (1)
  • Unlocking old behaviors
    • No registration up front and no deep dive triage
  • Dramatically different workflow for staff
    • Reduce scarce real beds to create more virtual beds??????
  • Patient perspectives
    • " I never got a bed!"
    • Privacy concerns
  • Physician issues
    • No compensation benchmarks for this kind of work. and it is uniquely different
    • EM MDs become internal customers.not comfortable position for them
    • Not every MD suitable for D2D, requires great risk stratification skills

Slide 28

• Requires a leap of faith (2)
  • New roles to manage with odd job descriptions
    • Flow techs and flow nurses
  • Administrative issues
    • "Only the uninsured leave"...not so
    • Its not about the expense, its about the return (ROI)
  • Staffing paradigm shift
    • MLPs and LPNs...may be perceived as threatening
    • Forget FTE hrs/visit...think cost/visit
  • Rules!
    • Lean processing at registration and quick look
    • Intake beds must be protected at all cost...almost.
    • Accountability for the WR
    • Internal queuing always...not in the WR

Slide 29

Joe Guarisco MD FACEP
jguarisco@ochsner.org
504-842-4433