The Positive Impact of Establishing an Internal Transfer Center
This article was first published in Nurse Leader | Read Now
Sharon Simmons, MSN, RN, CPN, and Shannon Baum, MSM
Health systems are facing greater pressures than ever before, with factors ranging from mergers and acquisitions and changing reimbursement models to capacity challenges and staffing shortages. A transfer center, where with 1 simple call from a referring physician, a decision to accept a critically ill patient can be made, placing them at the most appropriate level of care, the first time. Baptist Health in Jacksonville, Florida, went from an outsourced to an in-house center in 3 months-in the first 28 days alone, patient transfers increased from 900 to 1,500, growing to an average of 1,583 transfers per month.
OVERVIEW
Health systems are facing higher pressures than ever before, with factors ranging from mergers and acquisitionsand changing reimbursement models to capacity challenges and staffing shortages. A health system command center is an effective way to create a centralized approach to quickly and easily accept patients into the system from all points of entry and place them at the most appropriate level of care, the first time. There is shared situational awareness across the system when operational alignment is achieved caregivers can deliver world-class care and patients can receive the support they need during their health care journey.
One critical component of a health system command center is a transfer center, where with 1 simple call from a referring physician, a decision to accept a critically ill patient can be made. The key decision that systems need to make, however, is whether to manage the transfer center in-house or outsource it to a third party entity.
For years, it made financial and operational sense for Baptist Health in Jacksonville, Florida, to outsource its transfer center. How ever, in 2017, while renegotiating the contract with their third-party entity, Baptist learn ed that the company was significantly raising its cost per case. With patient volume steadily increasing, a decision needed to be made either to continue with the outsourced transfer center or build one internally.
ABOUT BAPTIST HEALTH JACKSONVILLE
Founded in 1955, Baptist Health is the area's only locally governed health system. Its mission is "to continue the healing ministry of Christ by providing accessible, quality health care services at a reasonable cost in an atmosphere that fosters respect and compassion ." Comprising 5 hospitals and 3 freestanding emergency departments (EDs), the system has 1,168 beds and 11,085 team members. In 2018, Baptist Health handled 72,39 1 inpatient admissions, 326,298 emergency room visits, and 46,896 total surgeries.
Baptist Health is recognized as a national leader in the use of clinical information technology to improve the quality and safety of care. All 5 hospitals and their home health agency earn ed Magnet® designation, in addition to being Jacksonville's "Most Preferred Healthcare Provider" since 1990, based on the national Research Corporation's Health care Market Guide.
Jacksonville is a growing area where close to 30% of the population is over the age of 55, which puts additional stress on Baptist Health's ability to meet the needs of the community. Baptist is also located in a highly competitive environment with several neighboring health systems. With Baptist's transfer center outsourced, it was difficult to determine how patients were brought into and moved through the system across the system's 5 facilities. When problems occurred in the transfer process, there were barriers and time constraints for solving them. Data was also difficult to access, leading to uncertainty around the reasons patients were being declined. Finally, the lack of a centralized approach resulted in unhappy physicians who had difficulty placing patients, along with long hold and wait times for those patients.
KEY POINTS
• Health systems face operational pressures—mergers, changing reimbursement models, capacity challenges and staffing shortages.
• A transfer center is an effective way to implement a centralized approach to accept patients into a health system from all points of entry and placing them at the appropriate level of care.
• Baptist Health established an in-house transfer center in 3 months, increasing transfers to 1,583/month.
CENTRALIZATION AND HURRICANE PREPARATION
The journey to centralization began in August 2017 when the decision was made to create a Patient Care Logistics Center (PCL C) to manage centralized staffing and bed placement. The PCLC co-located staff and illuminated for the first time aU beds within the enterprise: 5 hospitals and 3 free-standing emergency centers, covering approximately 52 square miles. Additionally, the centralized view allowed teams to work together more efficiently and provide appropriate, safe patient care; bed placement; and equitable staffing assignments with the dispersion of float team members. This first step was a significant change because previously, those responsibilities had been handled at the individual campus level.
One month into the project, a hurricane led to 2 hospitals being added to the mandatory evacuation zone due to the building's proximity to waterways and chance of flooding. The team had to quickly devise a process to handle reassigning a large number of patients, as well as making sure that they could identify the patients and return them to their original center of care once the hospitals and roads re-opened. The nurse leaders established a team comprising each facility's house supervisors, bed control team members, and transport liaisons. All team members were chosen internally: House supervisors turned over some roles and tasks, such as staffing and bed placement. As these functions became centralized, staff started floating to the like units that were understaffed- previously, some staff members were working overtime while other units were sending staff home because no one could see the whole picture.
For years, outsourcing the transfer center's functionality met Baptist's needs, and just as importantly, it was financially viable. The timing was perfect for making a change, however, because the successful evacuation and repatriation of patients during the hurricane led to discussions about the direction the transfer center should take. Senior leadership knew that Jacksonville was growing, and the system was growing too- Baptist MD Anderson Cancer Center had been added, along with additional service lines. There was also a customer service component to this decision; the team knew they could provide exceptional service because they were sensitive to the specific needs and intricacies of the local market. For example, there were multiple health systems in proximity to one another, and the outsourced transfer center often would life-flight a patient that was 2 miles away, instead of using ground ambulance transport because they didn't understand that the hospital was right down the street.
To continue moving the transformation to an inhouse transfer center forward, continued senior leadership engagement and involvement from all facilities was necessary. Baptist's chief nursing officer (CNO ) led the way by making arrangements for the planning/implementation team to present to every medical board at all 5 hospital s- as well as to service line chiefs- to help ensure staff at all levels were just as engaged as the executives. Both the CNO and the medical director helped lead these conversations, with the medical director leading the physician conversations with the CNO beside him, and the CNO leading the nursing conversations with the medical director beside her. The meetings were designed to gather all staff members' input into the overall process.
As conversations continued into Fall 2017, the outsourced transfer center vendor advised that a contract extension was not an option. Consequently, if the transfer center was going to be brought in-house, it would need to be fully operational by January 2018. The team quickly determined that the outsourced transfer center should be brought in-house and folded into the PCLC to create a health system command center.
With all the facilities aligned and the staff engaged, the planning team met the deadline and the transfer center opened on January 2, 2018. In the first 28 days, patient transfers increased from 900 to 1500. Currently, Baptist Health has an average of 1,583 transfers per month, including internal transfers from free-standing emergency centers and referrals from community hospitals.
RESPONSIVE SERVICE AND ACTIONABLE METRICS
The new transfer center is responsible for 4 phone lines: a children's line, a brain line, a ST-segment elevation myocardial infarction (STEMI) line, and a general transfer line. These lines were created to make it easier for the customer or the referrer to reach the right person for the fastest placement. For example, a pediatrician can call the children's line and is guaranteed to speak to a nurse who is an expert in pediatrics. This also applies to the brain line and the stroke line, as these calls are associated with high-intensity, time-sensitive situations and require a nurse to receive the call first, before it rolls to the coordinators.
Reports on how many calls come into each line were generated. In addition, the team began to closely monitor all outbound patient transfers. There is also a strong focus on monitoring those transfers and agreements, and all planned and unplanned direct admissions from a physician's office were entered into TeleTracking-- the vendor that powers the technology in the command center. In October 2018 alone, 121 patients were entered into the system as direct admits.
The Patient Care Logistics Center Project
The work was completed in phases because the new department needed to be resource neutral. All facilities worked together to donate partial resource hour s. The PCLC Staffing Matrix needed 11.2 ITEs, and with donations, the result was a deficit of 1.69 ITEs, meeting the team's goal.
Phase I
• Centralized staffing office to provide enterprise-wide visibility
• The pilot of staff floating intrafacility as appropriate. All call-outs, cancelations, and movement of staff
routed through the PCLC
• Centralized bed placement creating capacity with patient flow to meet demand
• Continued coaching of acuity tool for equitable and bal anced workload with patient assignm ents
Phase II
• Incorporated the transfer center from an outsourced provider
• Monitored and improved operations with continuous improvement methods
• Developed monthly dashboards for reporting
Three core best practices were identified:
1. ACCESS: provide an opportunity for patients in the community to have access to Baptist Health.
2. EFFICIENT AND EFFECTIVE PATIENT PLACEMENT: ensure that patients are placed in the appropriate unit in a timely manner that best meets their medical needs without prolonged wait times.
3. DATA: provide data to drive change.
The goal was to optimize internal labor resources across the entire organization to decrease premium labor expenses, such as overtime and use of external contingent staffing resources. Through the PCLC and the transfer center technology, Baptist Health has better control of labor costs, has increased patient transfers, and improved physician satisfaction.
For example, a daily communication regarding the capacity at each facility was developed and is emailed at 6:00 a.m. each morning to all hospital presidents, house supervisors, and EVS and emergency department leadership. A projection of discharges and admission s, based on the average of the last 4 weeks, by the day of the week, are also included in the daily report. Because of these changes, improved communication, nursing's adoption of the system, and effective utilization of data, the entire health system has undergone an incredible cultural shift by prioritizing patient throughput. In addition, the Health System Command Center has generated tremendous results over a short time, making it possible for Baptist Health to provide more services, to more members of the community (Table 1).
Physicians were very positive about the responsiveness and flexibility of the centralized, in-house approach. With the old outsourced system, if there was a problem with the technology and a change was needed, it took 2 to 3 weeks at best to resolve it. With the transfer center in-house, changes are made in 2 hours and sent out to the teams. Another benefit to the in-house center is the fact that Baptist staff has access to physicians' phone numbers and can connect to them directly- something the outsourced center did not have, resulting in delays as they waited for answering services to call back. Baptist also has CORTEXT, which is a Health Insurance Portability and Accountability Act- complaint text application that makes it possible to text information to physicians. Direct physician access via phone and text has been considered an unequivocal success by physicians, nurses, and transfer center staff.
So, although the ability to bring patients in and appropriately place them was certainly beneficial, it was just as advantageous to have access to data about the patients that were being declined. Before the transfer center coming in-house, the team had no idea how much volume was being lost, a knowledge gap with significant impact because volume was being affected by unhappy physicians, long wait times, long holding times, bed management issues, and issues with physicians not connecting right away. Now, the team can dig into these cases, work through the challenges, and escalate them to management if appropriate. In addition, an e-mail is sent each day to the president of each Baptist hospital regarding any patient that was declined so they can understand how many and why.
To have a complete understanding of the situation, each case is scrutinized. The attention to data also includes monthly dashboards to monitor the transfer center volume totals, as well as the accepted total, the percentage of accepted cases versus the total, the denial cancellation percentage, and the percentage of accepted volumes year over year (Table 2).
Metrics specific to STEMis are also being monitored closely. A daily report is generated with information that includes how many have been received, and if the 5-minute metric for notifying physicians, arranging transport, and contacting the cath lab is being met. Every STEMI is reviewed weekly- something that couldn't be done in the past.
Reports are also generated regarding emergency center metrics based on bed placement, including the percentage who left without being seen, the average patient length of stay, the hours in the emergency center, the treat and admit length of stay, and the emergency center boarding total hours are generated.
LOCATION AND STRUCTURE
It is considered a best practice to not situate a health system command center in the middle of the inpatient areas of the hospital. The PCLC is located in an on-campus pavilion that houses doctors' offices, a restaurant, and a pharmacy. This location works well for the team because as a coastal city that is exposed to hurricanes, being on campus provides access to essential emergency power.
Because of the extremely tight time frame due to the contract ending with the outsourced vendor, it made sense to staff the new center with existing Baptist employees who were already ingrained in the culture and processes. The result was a total of 24 full-time employees coming together to work collaboratively on staffing, bed management, and the other operational aspects of running the transfer center.
Again, in keeping with best practices, the center functions with 1 staffing nurse, 2 RNs, and 1 coordinator 24/7. During peak call times from 11 a.m. to 8 p.m., 3 coordinators are on staff. Another staff member handles the system's other 4 facilities: Baptist South, Baptist Beaches, and Baptist NASSAU locations, as well as Wolfson Children's Hospital. However, during the overnight hours, 1 person handles all 5 hospitals.
CHANGING OPINIONS AND MARKETING THE CENTER
The ability of the 24-member team to build relationships with customers has been another major benefit of the PCLC. Whether it's a physician at the freestanding emergency center that's trying to get a patient placed, or a physician who is trying to get a patient a heart cath, relationships were built, and now there's a sense of trust that was not there before.
Those relationships were strengthened by the metrics, which have skyrocketed in all respects since day 1. As an example, 1 of the neurosurgeons built a program that he's very proud of, but he was nervous about the changes that were being implemented. The PCLC team collaborated with him over meetings prior to opening so they could understand the urgency of time when dealing with neuro patients. After week 1, month 1, and month 3, the team lived up to all physician expectation s and are meeting all of their time-related metrics.
Communication with the freestanding emergency centers was also improved with the creation of an e-form. Because freestanding EDs feed into hospital transfers, an online form was implemented that makes it possible to fill in the main pieces of information in TeleTracking so that work can start on the transfer for a nonemergency patient without a phone call. Then all that is required is a call back to say, "Okay, we're ready to connect physicians." This not only eliminates repeating the process, and the need for multiple phone calls, physicians stay informed every step of the way because they can see that a case has been opened online.
As the center evolved, the team quickly realized that the customers are not just the patients outside the Baptist system, they are also the patients inside the system, the physicians in the emergency rooms, and the nurses at the emergency rooms. All of these different sets of customers are targeted - something that wasn't happening before and has further enhanced the success of the PCLC.
The PCLC also now provides the ability to divert patients to one of the community hospitals when capacity has been reached at the central downtown location. It is possible to see what is available across the entire network and let the person calling know that while there may not be space downtown, there are beds at one of the other sites that can accommodate that patient immediately.
One of the administrators who played an integral role in implementing the in-house transfer center from the beginning said it best, "We have the eyes of the kingdom now, so we can see everything." It is possible to know the availability across the system, and say, "Okay, this morning we're not going to send any patients downtown unless it's a service line-related issue."
If it is a patient with a brain issue or a child, they have to be sent downtown, but other patients can be sent to other campuses. That was another option the outside company did not provide.
RESULTS
Baptist Health underwent a significant cultural shift, starting with the implementation of a patient care logistic center (PCLC) through the development of a health system command Center, which resulted in improvements in patient throughput. The center has led to tremendous results over a short period of time, and Baptist Health has been able to provide more services to more members of its growing Jacksonville community.
• The best practice "one call" approach for direct admits has enhanced Baptist's reputation and increased transfer volume, and consequently revenue. Less than 5% of patients being transferred to Baptist are denied or canceled.
• In the first 28 days alone, patient transfers increased from 900 to 1,500. Currently, the average is 1,523 transfers per month. This also includes internal transfers from free-standing emergency centers and referrals from community hospitals.
• Valuable staffing resources are being more effectively allocated, with people from like units being placed where they are needed most- a significant culture change that has been positively received. Overtime costs were cut by more than 40% as a result of the new centralized staffing model (Table 3).
• This level of attention to the patient mix made it possible for Baptist to save between $800,000 and $1.2 million in 2018.
• Emergency center boarding hours declined 20%.
• A patient's leaving without being seen decreased by 6%.
IMPLICATIONS FOR OTHER ORGANIZATIONS
As stated previously, health care systems are facing greater pressures than ever before-- the process of reviewing workflows, assessing staffing, and implementing technology are a key part of launching an effective, centralized transfer center that increases both efficiencies and revenue. In addition, as care models and reimbursement incentives transition from volume-based care to value-based care, having these types of systems in place becomes even more important. And as independent hospitals continue coming together to form hub- and -spoke systems with a single regional specialty care center serving as the hub and community hospitals as the spokes, and as hub-and-spoke systems came together to form integrated delivery networks, the need for centralization gains further importance. In 2018, there were approximately 550 integrated delivery networks, which combined include over 5,500 hospitals with nearly 900,000 in-patient beds. In 2016, across the United States, 9 1.6% of all hospitalized patients were discharged from an integrated delivery network. Furthermore, using the information generated by the transfer center, organizations can realize visibility across their health system, reduce the costs that result from waiting for care, and align resources to meet the demand for patient care.
CONCLUSION
Establishing a transfer center, and specifically establishing one in-house, ensures that the staff is familiar with the local landscape, that patients are transported in the most effective manner; that strong relationships can be built with the physician community; and that it's possible to see availability across the system and divert resources accordingly. The end result is a better experience for patients and caregivers.
There were many collaborative partners who made this project successful. Special acknowledgment to our Chief Nursing Officer for Baptist Health, Dr. Diane Raines (retired ) for all the guidance, and support throughout the creation of the Patient Care Logistic Center. Also, acknowledgment to Dr. Matthew C. Rill, CEO of Emergency Resources Group, and Mr. Michael Mayo, Hospital President of the Jacksonville campus, for the ongoing medical and administrative direction and guidance to the Transfer Center. Sharon Simmons, MSN, RN, CPN, has worked at Baptist Health/Wolfson Children's Hospital in Jacksonville, Florida for over 35 years. She is currently the manager of the Patient Care Logistics Center (PCLC). She was chosen from Baptist Health as the Nurse of the Year for Professional Collaboration in 2018. She can be reached at Sharon.simmons2@bmcjax.com. Shannon Baum, MSM, has worked at Baptist Health/Wolfson Children's Hospital for the past 14 years. She is the director for FLEX (staffing team) and the PCLC.