Less than 19 minutes.
The DAISY Award for Extraordinary Nurses in Patient Flow honors outstanding nurses and their teams for their commitment to patient experience, optimizing care coordination to enhance patient flow, delivering the highest quality of care with compassion, and regard for the unique needs of the patient. Kim Jefferson from Swedish Medical Center, the 2018 Individual winner, was responsible for leading a patient throughput effort to move patients efficiently through the hospital to ensure they get the care they need. She shared her thoughts on the importance of patient flow and the steps that she took that led to a steady decrease in the percentage of patients holding in the emergency department and a decrease in time from patient admit (from the ED) to occupied bed (unit room).
Listen Time: 18:43
Director of Throughput, Patient Flow and Nursing Supervisors at Swedish, division of HealthONE
A nurse for more than 37 years, Jefferson is responsible for ensuring patients have a seamless experience as they are transported from the emergency department to the most appropriate inpatient area for care. The end result is a positive experience for the patient and their family.
The volume Kim handles is significant—the Swedish emergency department sees approximately 200,000 patients each year and these patients benefit from her relentless ability to address issues with patient flow―from process and personnel issues to bed availability during times of high census.
Welcome to the Patient Flow Podcast powered by TeleTracking. On today’s episode, TeleTracking Clinical Advisor and nurse of thirty plus years, Maria Romano, introduces us to Kim Jefferson, the recipient of the second annual DAISY award for extraordinary nurse in patient flow. Kim works for the Swedish Medical Center in Englewood, CO. She was recently honored at TeleTracking’s client conference, where Maria took a few minutes to chat with her about her passion for patient flow.
Kim: I'm actually a Colorado native. Born and raised in Colorado, went to nursing school in Colorado, as well. Went to Nursing school right out of high school. I started nursing in 1981, and I actually started nursing at a sister facility that is affiliated with the hospital that I work at now. So, I was there, like, sixteen years, mostly did Orthopedics, that was my background for floor nursing. And then I did some management, and then I moved on to...did Home care for a couple of years, which I really enjoyed.
And then after that I went to work for another competitor, a level one trauma center in the Denver area. I was there almost eleven years. And then the...most of the management team, the division that I was in, or the level that I was in, got laid off, so at that time I started my Master's. So I got at least my foot in the door getting my Master's in Health Service Administration from Regis University.
And then I started at Swedish, in, it’ll be about nine years, next month. Kind of what I am doing now. But it was a brand new position as a Bed Management Coordinator and it was a brand new program to have someone 12 hours a day, five days a week managing assignments and getting patients to the right place. So I started that about nine years ago and then I moved up to a manager and now I'm the Director of Bed Management. And then the nursing supervisors that we have 24/7 that carry on when I'm not there, report to me.
Maria: And how many beds are you licensed for in your hospital?
Kim: We are licensed for 408.
Maria: Okay, Alright. So, you've got a huge opportunity here, right? With making sure that every patient gets the right bed at the right time in your organization.
Maria: So, tell me this...what's your passion? Why is your passion for nursing?
Kim: My passion for nursing actually started when I was, like, five. My grandmother was a nurse and it was just something that I always wanted to do. Helping people. I was always wanting to stop at accidents and see what was going on and trying to...my family. Whenever my brothers were sick or anything, I always wanted to try and take care of them. I grew up with three brothers, so I always wanted to take care of them. And I think just following in my grandmother's footsteps.
Maria: And how did you get so interested..I know that you received this position, right, when you came back to Swedish. But what really captured your interest with Patient Flow?
Kim: Correct. Well, as I was talking to my husband the other day...I think what started was…of course, after being laid off, you just kind of think about "okay, what do I want to do?" I mean, I had been in nursing almost, not quite, 30 years. So, it's like "okay, what do I want to do for the next ten years?" Or, whatever.
Actually, this position became available and this kind of interested me as far as you have a connection to the patient, but an indirect connection. So, you can at least, still make sure that the patient is getting what they need, kind of in an indirect way. Plus I'm very, kind of, analytical and process driven, and it just..like a big puzzle. And now that I've gotten into it, that's probably what gets me excited is it's just like a big puzzle. As our CNO says, it's like a big game of Tetris. "Kim just does a great game of Tetris, just trying to figure out all these different pieces. And you've got to balance the PACU and the Direct Admits we have coming in and GI Lab and Cath Lab and we've got three ORs and then the ER. So, we've got a lot of different points of entry you have to figure out.
Maria: Yeah, absolutely. And I think you've seen the change in the landscape of health care too, throughout your years of practice in your profession. Which, with you being in this role right now is so very, very important to make sure that patients are receiving the right care at the right time and being efficient in your Hospital's system. So, with that being said, can you discuss what your focus was for you to receive this award with the ED workflows?
Kim: It was really looking at developing a process that we could decrease the length of time in the ER. Of course that was one of the main goals. And to really look at how could we get the patient out of the ER to the right place. And whether it's a...we have a Trauma Unit, we have a Neuro Unit, we bring patients in from Multi-State Region Trauma, Neuro, and Cardiac. And so it was really looking at being the most efficient, as well as decreasing the length of stay, decreasing the admitted length of stay in the ER. As well as decreasing our whole time.
As a large institution that has capacity issues, we have capacity issues at times because our slogan out in the community is Take Me To Swedish. And sometimes, it's like' everyone wants to come to Swedish. We started as a Community Hospital, but we built into a..still a Community Hospital. We're in a suburb of Denver, but bring in a lot of different people. So, I think the focus was, again, decreasing the length of stay in the ER, the admitted length of stay, and getting the patient out in the most efficient and quickest way possible.
Maria: So, share with us what was your steps in this approach, with this initiative.
Kim: So, a couple of things. One is really looking at their several..and TeleTracking their several reports, that I look at on a daily basis that are actually...I've got one that is direct email to me, that I've got set up. It's in the custom reporting system. It's process time analysis, so really looking at the request time, the sign time, and then the occupied time. And really looking at that to make sure that we're getting the patient out within that 59 minutes. And so we had some great success about 3 1/2 years ago when we went live with CPOE, Computerized Physician Order Entry, where the physician puts the order in and it automatically interfaces and activates the order in TeleTracking. Which was awesome for us, because we had..at that time, we did about a three month data, where the physician would hand the order to the clerk and it would be like, maybe fifteen minutes, maybe twenty, maybe ten, maybe five, maybe twenty-five before the order went in. Well the clock is already ticking once the timed order is on the physician order.
And so that really helped to bring that down to like zero to one minute. And then we've got the rest fifty-seven, fifty-eight, almost fifty-nine minutes to get the patient out. So that has really helped. The other thing that we've focused on as well as on the other side, not in the ER, but on the nursing side was the Discharge/Discharge Entered, really focus on that. That's another report that I pull up. It comes through, I think, is the Bed Management Report, to really look at are the nurses taking the patients out when they actually depart? And we've seen gaps, but I think that gap has shrunk. The gap was..the goal is ten minutes, but the gap was nineteen, twenty, twenty-five was the average. You had some people put them at an hour. So really talk to the nurses, the charge nurses, which we have what we call a bed huddle, three times a day. So talk to them about the importance of..as that patient's discharging and we've got a couple units that really do a really good job at getting the patient out as they're actually leaving. They do kind a spot check right at the desk and they scan them as they're departing the unit. So, we're really trying to make sure that the patients are discharged, because there is that timestamp of Discharge/Discharge Entered that back-times.
Maria: How did you communicate and train the staff?
Kim: One of the things is that we have what we call an ED throughput committee, which we're kind of changing the focus a little bit because we've streamlined the ED so well that we're really changing the focus, really for the whole hospital. But, it's getting developing partnerships with the key stake holders, which are the Charge Nurse, Directors of Patient Care, the ED Department, Transport, EVS..so really kind of getting all of them on board and attending the meeting with their input. And there are times that we tried this…we tried this approach, we tried that for a while. "oh, that's not quite working." Because there's a lot of communication, because the ED uses Meditech, and so they have an ED Tracker, and so we put comments in there once we've assigned the bed. So just to communicate to the nurse, to the secretary, plus we have the pagers. So we get a page when a bed is assigned. But, we're looking forward to, hopefully, automating a lot of that stuff so we don't have to depend on the pager. And really we had, I think, some good success and people were on board. Because people want to get the patients up to their unit. There's a lot of units that..they have an empty bed and they're calling me saying "hey, I just discharged, so you have anybody for me?" I mean they want to get people up there, so..
Maria: Yeah. High-five for that one, for sure. Because that's a culture change, right?
Maria: Especially within clinicians. Because we--that's pull methodology.
Maria: You've created a pull methodology, right. You know, a pull theory. So, one thing too is..your slogan that you're using, share it with the audience, the in-house patient flow.
Kim: So marketing put together..we did a..Swedish has a Facebook page that's for Swedish employees. And so they had a slogan that they put out and they wanted people to either put pictures..it was mostly pictures, like "Ready For The Next Patient". So people were doing all sorts of stuff like, they were in checking beds, a nurse was in with EVS and they were finishing mopping the floor and they were just doing all sorts of creative things. But I think to get everybody on board with "Ready For The Next Patient", and again along with the "No Patient Waits". I think it goes kind of hand in hand with that.
Maria: And then, you're seeing great results, without a shadow of a doubt.
Kim: We have seen great results.
Maria: I want to hear all about those great results, because this impacts all of us. These are our loved ones that are waiting for care, right? In the ED, and waiting to be seen. So share with the audience how this is impacted.
Kim: Well, as we go along, we get our patient satisfaction scores. So patient satisfaction, I think, has definitely been on the rise in both the inpatient and the Emergency Department. So when we were inpatient we were in the mid to high 60s. Our latest rating was, I think it was 80.3, and that's with our division. So, we're in the...we're part of HCA. Health One is part of HCA. And within our division, which is a continental division, I believe we're ranked either number one or number two within all of our hospitals there. As well as the Emergency Department. I think the last Emergency Department was number one. Number one, we are number one. Within Health One, which is about eight hospitals, in what we call the Continental Division.
So, anyway number one for inpatient satisfaction and we really strive on inpatient nurse leader rounding. And not only that on the in-patient units, but we also focus, if we are at a point of capacity, which we do have. We have beds down, right now, for construction. And we had beds down for flood remediation. We had a flood a few months ago, so we had beds down for that. So there are times when we've had a hold in the ED, in-patients in the ED. And so the expectation is that the nurse leader of that unit that the patient's going to rounds in the ED and introduced themselves to the patient. I think that really starts the chain of getting the patient then up to the unit.
Speaker 2: And what other results have you seen with the metrics in the ED lengths of stay?
Kim: We've also seen decrease in our hold time, our hold percentage. A year ago January, we were at a 57% hold. This last January, we were down to thirty-some. And we have days when we're twelve, seventeen, twenty-four, twenty..And I think really focusing on the avoidable hold..we get an avoidable hold report as well. And so..
Maria: Yeah, let's go to that. You shared that with me yesterday and I'm so excited for that. So you're taking the processing Time analysis, which comes to you from our Custom Reporting.
Maria: So you have that delivered in your mailbox bright and early every morning from the day before. Right?
Maria: And then you are auditing that, right?
Maria: The Processing Time Analysis. And then you're looking at the avoidable days out of Meditech.
Kim: Right. It's an avoidable hold out of Meditech. Right.
Maria: Yeah, explain that.
Kim: So what that is is…Avoidable Hold is anything that is an avoidable hold is characterized as any bed that is vacated at least 65 minutes before the Admit Order is written. And the reason behind that is they feel that between 65 minutes before and another 59 minutes or 60, you've got almost 2 hours to get a bed clean and ready for the next patient. And so anytime in that timeframe, if a patient doesn't depart the ER, then it's considered an Avoidable Hold. But I also dig down and look at when the bed was vacated, I look at when the bed was assigned. Because we only assign clean and ready beds.
We tried that in the past, as well. We tried to assign "in progress" beds, we tried to assign "STAT" beds. For a while we did "hallway bedding", and that didn't work. So, we've really gone to "clean and ready" beds, so we really know where it lies. Does it lie then with the ED? Or with EVS or Transport? Or does it lie with Nursing? So I just compare those and then I send that out daily, once I gather all of that and re-do the spreadsheet and send that out to the ED, the ED Avoidable Team. And then, also, send it to the directors of the units that were impacted, the director of the units that had the hold, or maybe they didn't discharge the patient. That discharge/discharge Entered was greater than...I usually do greater than twenty minutes, I know the goal is ten. But usually anything greater than twenty minutes. But if they have a thirty or forty minute delay in getting the patient discharged out of Meditech, then that bed could have been cleaned in that time. When it's just sitting there, and nobody knows that we have a dirty bed.
Maria: Alright. Two more questions. The first question, does your senior leadership team at Swedish support you with your patient flow initiatives?
Kim: Yes. They do. I think the whole leadership team, everybody from the CEO, to the CNO, the CFO, the COO, the VP of ED, I think really...as our CFO has said, 'Kim is like a dog with a bone." You give her a project, and she's on it. I think they all support getting the patients and support what I am doing.
Maria: Yes. When we do work for their clients who are trying to build a strong framework for patient flow in our hospitals, the first sign of that is to have a strong senior leadership supporting patient flow.
Kim: And the ACNOs, I would have to say yes. The ACNOs are the ones who actually nominated me for this award.
Maria: That's awesome. And last, what does it mean to you to be recognized by DAISY and TeleTracking for extraordinary care that you've given in patient flow, for the patients that have received it in your hospital? If you can summarize that.
Kim: Well it's definitely an honor, very humbling.
Maria: I think we both love being a nurse, and watching you get emotional over this makes my heart so happy. Because it's such a noble profession touching humanity. And I want to thank you from TeleTracking and from DAISY for what you've done. Because it's not easy. It's not easy to be the culture changer.
Maria: And that's what you are, as a nurse, To make sure that your patients are getting the care that they need. So thank you, Kim.
Kim: Thank you. I have one more thing. Where's my card? So, I have a card from...so developing relationships is huge. And so I'm just going to read this card. So I got this card from the charge nurses on Six Med Tele. Which is a unit that is under construction, they have double rooms, sometimes we have to double patients up. Anyway, they just said "The Six Med Tele CnCs just wanted to thank you for all of your hard work. You are always willing to listen to us, collaborate with us. And we appreciate the trust you give us. Thank you for all that you do to ensure our days run smooth. We would be lost without you. There is no other Bed Management Nurse like you. You're simply the best and we love working with you."
Maria: Beautiful. Congratulations, Kim.
Kim: Thank you.
Maria: You're very special and I'm privileged to have interviewed you and to get to know you. So thank you for all of the hard work you're doing. And keep doing it.
Kim: Thank you very much.
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Less than 19 minutes.