Patient transfers can be stressful for patients, families, and care teams—even under ordinary circumstances. If the right processes aren't in place, there are risks of miscommunication, incomplete information being shared with the right clinicians and departments, and delays in treatment. When the patient is a child or infant in need of immediate, critical care, the risks and stress levels increase dramatically.
As the only tertiary children's hospital in a 31-county area in rural South Texas, Driscoll Children's Hospital (DCH) understands the seriousness of seamless and timely communication. Each day, we receive dozens of requests from primary care physician offices, specialist offices, acute care clinics, and rural hospitals to transfer their young patients to our ED, Level IV neonatal ICU, pediatric ICU, or other on-staff specialists. Like many hospitals whose volume has grown over time, DCH relied on manual, asynchronous processes for intake. Although this system was working adequately under the circumstances, it became clear that it would no longer be sufficient as call and transfer volumes increased.
Hospital leadership recognized the need for developing a centralized, streamlined approach to enable transferring facilities to call one phone number to complete the entire transfer approval process, launch the transport and admissions process, and automate the process of getting all the right information to all the right people at the right time within DCH.
Mapping workflow gaps
To develop the Driscoll Access Center (DAC), which coordinates all patient transfers to the hospital from other healthcare facilities across 31 counties, we initiated a literature search; however, there was a gap in the literature that revealed little information regarding transfer centers. We then reached out to other facilities that had developed or were developing transfer centers. The feedback we received was that we were further along with development and technology, and they requested that we share our processes and lessons learned. Next, DCH leaders interviewed and selected a consultant partner to evaluate the current processes and technology available, and match those against the hospital's present and future needs. Evaluating standard workflows, the team realized the need to optimize the DAC. The project's overarching goal was to streamline external and internal communication, making it faster and easier to transfer patients, connect clinicians in a timely manner, and ensure that all relevant information was available at the point of care.
The transformation was broken down into three phases. The first phase involved a detailed assessment of the current state by the consultants, development of a go-forward strategy and business plan, and design of the system. Phase two involved implementation of the plan, including technology integration, organizational structure, and development of clinical scripts and protocols to enable nurses to make quick patient approvals without the need to consult a physician. The final phase was the go-live, which included training, optimization, and the use of data modeling for evaluation and improvement.
Each of these phases required multidepartmental input from across the entire organization. Stakeholders from the DAC, admitting, transport, ED, human resources, information technology, business development, community outreach, and telecommunications, as well as physician leaders, residents, nurse leaders, unit secretaries, charge nurses, and more came together to offer input, discuss workflows, and ensure that the result was optimized for efficient patient transfer and care.
Ultimately, six strategic goals were established for the DAC:
- Assess the DAC's current state in support of a design process, resulting in a state-of-the-art, future-oriented service.
- Advance and strengthen the hospital's vision to be the regional and international leader in children's services.
- Leverage a technologically advanced access center to help address health disparities and healthcare needs in South Texas.
- Grow the hospital's reputation as a pediatric tertiary care provider across the 31-county service area.
- Optimize the DAC's processes to maximize efficiency and eliminate waste using proven Lean Six Sigma methodologies.
- Integrate and leverage already invested telehealth and telecommunications technologies.
Optimizing patient access
A team-based analysis of the current state revealed that many of the admissions and transport processes were paper-based, requiring multiple phone calls and faxes, as well as the use of a pneumatic tube system to carry certain critical information from one department in the hospital to another. This outdated approach resulted in delayed care, longer turnaround times to accept patients, and frustrated families and healthcare providers. Additionally, the same information often had to be repeated to various healthcare providers and staff members due to the 1:1 nature of the asynchronous communication.
Evaluators also discovered that the telecommunications infrastructure at the heart of this system had many disparate, outdated components, further hindering communication both internally and externally. At the same time, process improvement exercises conducted by certified Six Sigma black belts identified new and efficient workflows, as well as ways to reallocate resources and roles to facilitate better processes. Current and ideal processes were mapped, with the goal of eliminating the eight common wastes: defects, overproduction, transportation/unnecessary movement, waiting, motion, inventory, overprocessing, and human potential.
Building the infrastructure
With this information in hand, a business plan was completed specifically to address the issue of the outdated call center telecommunications system. The plan identified the opportunities, costs, and benefits of replacing the DAC's landline phones with updated Voice over Internet Protocol (VoIP) software, which is an industry best practice. After evaluating several options, the hospital selected a VoIP-based call center software, which was integrated into the existing communication system that nurses, physicians, and other care team members use for voice-controlled, hands-free calls; broadcasts to groups; and secure messaging.
One of the driving forces behind the selection of the new infrastructure and software was the ability to deliver standard call center metrics, such as call volume (overall and by healthcare provider), regions of call origination, first call resolution, talk time, hold time, and other information to help the hospital evaluate the efficiency and effectiveness of the DAC. The software also needed to integrate with the hands-free badges and smartphone app that care teams use to facilitate communication and information flow within the hospital to eliminate the need for multiple calls, emails, and pages.
The ultimate goal was to make both the transport and admission processes faster, easier, safer, and more patient- and family-friendly to boost satisfaction and experience for all. As we got deeper into it, we clearly saw a need and a solution.
Before updating the communication system and process, significant effort was required to accomplish what should have been relatively simple, straightforward tasks. Take the admission process, for example. Whenever an outside or inside healthcare provider needed a bed for a patient, he or she would use a landline to call a nurse, who would write down the patient information. Then, the nurse would page or call a physician to relay the information, which often resulted in playing “phone tag.” Sometimes, the nurse would need to call or page several physicians at the same time to send the same information. If a response was required, each physician would need to respond individually, which could lead to bottlenecks because only one call could be answered at a time. It was a manual, time-consuming process that left nurses, physicians, and families frustrated.
Another example was the patient transport process from an outside facility or physician's office to the hospital. The referring healthcare provider would call the DAC, where the call would most likely be answered by a nonclinical communications specialist. The specialist would then have to page the accepting healthcare provider and connect the referring provider to him or her. Again, it was a time-consuming, manual process just to get the transport approved.
The net result was delays in getting patients accepted and transported to the hospital to receive a higher level of care. Sometimes, it was merely inconvenient, but often the long hold times and waiting for connections and approvals meant that a child would suffer the effects of the current condition longer. It also meant that healthcare providers who could be taking care of other patients were stuck waiting for answers. Clearly, the entire process needed improvement, which is why the DAC optimization initiative was launched.
The hospital's communication system had already proven itself effective across all inpatient clinical settings and by multiple clinical roles, so it was a natural decision to expand its use and integrate it with the new call center software implemented in the DAC. With the communication system's intelligent master directory, DAC staff members no longer need to waste valuable time looking up phone numbers or determining who's on call. They can reach the person they need simply by saying the role or group and, depending on the situation, they can choose the best communication option for the task at hand.
The first option is a wearable badge that enables users to communicate hands-free, receive secure messages and alerts, initiate and join broadcast calls to groups, and manage other communication needs. These badges are used by many physicians, nurses, and staff members. The second option is a smartphone app that's used by physicians, surgeons, nurses, rehab specialists, and respiratory therapists, among others, to communicate and collaborate. An advantage to the app is its touchscreen display that enables clinicians to share more data at once, along with photos, images, and other patient-centric information. The third option is a wearable smart badge that combines elements of the first two options. It offers the hands-free communication capabilities of the badge (among other features) while also incorporating a touchscreen that presents more contextual patient information. These smart badges are deployed in areas where more information is needed, such as in the ED and on medical-surgical units, and for unit secretaries and residents.
Integration of the call center software and the communication systems has simplified the admission and transport processes considerably. For admissions, external and internal healthcare providers only need to make one call to the DAC to request a transfer and/or admission for a patient. This call is now always received by a nurse on a recorded line who documents the demographic and diagnostic information, and then shares it along with the patient's history (if there is one), labs, and other pertinent information with the appropriate departments and people through the badges and smartphone app. As a result, while physicians are determining whether to admit the patient, admitting can already be working on finding a bed, saving critical time.
Incidentally, one of the most important changes in the process has been working with hospital physicians to establish criteria that enable nurses to automatically admit patients rather than waiting on physician approval. If a consultation is required, all the information goes out simultaneously to everyone who needs it rather than contacting one person at a time. Clinicians can easily scroll through the information rather than having to go to a separate system to look it up. Responses can also occur concurrently rather than waiting for a phone to free up. Conferences can be set up via the badges and app if a more comprehensive discussion involving several clinicians is needed. When an immediate response is required, the messages to the badges and app are marked “urgent.” This has been a boon to ED physicians, in particular, because hearing “urgent call, DAC physician holding” makes it easier for ED physicians to step away from the patient they're currently seeing versus simply receiving a page as they did before. Patients and their families are more understanding when they hear the urgent message.
The difference is also apparent with transports. Previously, the transportation team would wait until all other operations were finished before being notified of the need for a transport. Now, they receive alerts on their mobile devices immediately after the initial call to let them know that a potential transport may happen, as well as the nature of the transport, so they can prepare ahead of time. Once the admission has been approved, they can leave immediately, saving valuable time while increasing healthcare provider and patient/family satisfaction.
Although the new system has only been in place a few months, the hospital is already seeing positive results. The number of outbound calls to manage admissions and transport requests has been cut in half due to better, more efficient communication to more physicians and other healthcare providers. This has resulted in faster admissions, which means less waiting time for patients and families. And it's been a critical improvement for ED-to-ED transfers.
Average call times decreased to 3.5 minutes for quick admits, which is well below the industry benchmark of 6.5 minutes. The urgent message feature on badges in the ED has significantly reduced hold times for those physicians. And transports increased 20% in the 2-month span after implementation and were on-track to increase by 50% to 60% by the end of 2019.
Although everything is now running smoothly, there were certainly challenges along the way, not the least of which was one of the worst flu outbreaks in Texas history shortly after we began the integration. It definitely tested our processes and people but, in the end, that trial by fire may have been the best thing for proving the value of these solutions and improvements.
One of the smartest things we did was bringing in stakeholders from all the areas that would be affected and mapping out how we wanted the processes to work, such as who gets notified and how. Stakeholders weren't just from the leadership team. Bringing in frontline nurses who understand how things work—versus how they ought to work—and know the right questions to ask can save time during implementation and after go-live. It can also help drive better adoption of new processes and technologies. Of course, it's important to have a strong executive sponsor who believes in what you're doing and will fight for the integrity of the project, even when staff members are struggling and physicians are unhappy with the transition or progress. We had that strong support and were grateful on many occasions for it.
Ultimately, our goal is to deliver the best possible care for every child within our reach. With these new processes and systems, and our excellent staff, we feel like we're prepared to do this—not just today, but for a long time to come.