BY: RHODA WEISS
Ms. Weiss is a Santa Monica, CA–based health care consultant and speaker.
"Runways" are not just for airports. At Long Beach Memorial Medical Center (LBMMC) and its subsidiary, Miller Children's Hospital, both of which occupy the same campus in Long Beach, CA, keeping the "runways" clear for patient admissions has increased volumes by more than 160 patients per day and net income by 700 percent.
Senior managers, who are these hospitals' chief "traffic controllers," devised the "runway" plan in late 2002. With census falling below expectations and physicians voicing frustration at admitting processes, the managers took action.
The management team examined three major points of entry for LBMMC, a 541-bed adult hospital, and Miller Children's, a 198-bed pediatric facility: the admitting department, the emergency department, and the processes for transferring back capitated patients who were hospitalized out-of-network. At each they saw major bottlenecks. Working with many hospital departments, they began the process of clearing these three important "runways" to the hospital.
Fixing Admissions
First, the managers tackled admissions. Their goal was to gain physician confidence in the facilities' ability to efficiently accept all direct admit patients. Under the old system, it took a minimum of 50 minutes to inform a physician of the availability of a bed. "Physicians simply couldn't wait that long," says Judith Fix, RN, MS, chief nursing officer and senior vice president for patient care services at both hospitals. "Although we were their first choice, they found themselves referring [patients] to for-profit hospitals in the area just because we couldn't find them a bed." LBMMC and Miller Children's are not-for-profit institutions.
The management team knew that much could be done if it could provide physicians seeking admissions with more positive news. The team's goal was to assure each and every doctor that yes, there would be a bed available.
Thus the "Just Say Yes" program was launched. "It was a massive change for us all," says Fix. "Whenever a doctor's office called for a bed, we automatically said 'yes.' That meant staffing up and changing processes at our admitting department."
According to Fix, admitting staff rewrote their "scripts" for responding to doctors' offices. Vice presidents, too, participated in the program. If physicians didn't get a "yes" response within seven minutes from admitting, they were given direct access to VPs who rallied their staff.
Flyers, buttons, posters, and mass faxes also played a part. The marketing department swung into gear with "Just Say Yes" communications, faxing doctors' offices and distributing "Just Say Yes" rolodex cards. "We put our money where our mouth was," says Susan Solomon, vice president of marketing and corporate communications for MemorialCare Medical Centers, the Southern California System that includes LBMMC, Miller Children's and three Orange County hospitals. "We made a commitment and we did it."
Within weeks, the census numbers began to rise. Refusals for direct admissions went from close to 30 per month to zero. Many doctors also returned after months of referring to other hospitals. "We knew it could work," says Fix. "We just had to rally everyone to the cause."
Repatriation Begins
Next, the management team set its sights on a situation that was causing growing concern. Capitated patients who were hospitalized in out-of-network local hospitals (usually for emergency care) were becoming an increasing cost concern.
"We set a goal of transferring every patient who could be safely brought back to Long Beach Memorial and Miller Children's," says Tamera Florio, RN, JD, senior vice president of operations for both hospitals. "The medical center set a goal of getting a bed assignment for every 'repatriated' patient within 30 minutes of receiving a call from the out-of-network hospital."
"This was a win-win on many fronts," says Fix. "Our medical groups were glad to get their patients back and patients were happier being admitted to their preferred hospital."
The repatriation effort resulted in an increase of as many as 80 inter-facility transfers per month. "We were able to transfer about 97 percent of our patients," says Fix. "The medical groups and their physicians were thrilled and, of course, our census numbers rose again."
The Emergency Department
With two successful missions under their belts, the management team knew they had one more critical "runway" to address. The emergency department, long a source of pride for the medical center (it has been rated as one of the California ERs in which a patient is most likely to survive a heart attack) was also developing a reputation for long waiting times. As a result, paramedics were increasingly diverting patients to other medical centers.
First, the team sought to win back paramedic support. "We knew that the last thing paramedics want is to wait, so we started to assign patients beds when they were still with the paramedics in the field," says Richard DeCarlo, vice president of diagnostic services for both hospitals. "We also assured them that they would have to wait no more than five minutes from the moment they arrived at our door."
Paramedic liaison activities were also stepped up through visiting firehouses, improved education programs, and "just giving them better service overall," says DeCarlo. "And we worked to lessen the number of 'hours on divert,' the time when the hospitals' ERs are unable to accept patients because of an insufficiency of available beds, especially critical care beds. The paramedics wanted to know that we were ready for their patients, day and night."
Timing was also on the management team's side. When it began to focus on the emergency department, a major remodel was underway in the department and completion was just two months away. It gave the "go ahead" to begin marketing the greatly expanded emergency department and trauma center. It also began marketing a new ER "tracker"—a computer program that tracks patients' location and status—that would help manage patient flow. According to Solomon, flyers were faxed to physician offices, articles were pitched to the local newspaper, and billboards were put up throughout Long Beach, all touting the new and improved emergency department. At the remodeled department's grand opening the city's mayor remarked that she had recently accompanied a family member to the department and was personally impressed with the many improvements.
Six months after implementation, LBMMC's paramedic run numbers increased by more than 100 per month. Hours on divert also plummeted, from a high of 400-500 hours per month to close to fewer than 10 hours per month. Emergency admissions also soared from 58,922 in 2001 to 65,756 last year; 72,000 admissions are predicted for 2004.
"Everyone at the medical center made this work—the emergency department, nursing, admitting, discharge planning, home health, our doctors, administrators and housekeeping to name a few," says Byron Schweigert, PharmD, CEO of LBMMC and Miller Children's. "Pride of ownership made it happen. We all had a goal and didn't take our eyes off the ball."
When the facilities' combined census hit 600, their managers knew they had achieved a milestone. Florio ordered special polo shirts for the 8,000 employees, physicians, and volunteers. "I've read about teams working together and believed it could be done," says Florio.
Says Fix, "We had to change our culture and we did. Our team has been changed from the experience—for the better."
Copyright © 2004 by the Catholic Health Association of the United States
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