Bringing Silicon Valley inside Government
by Sanjay Kurani, MD and Clifford Wang, M.D., M.P.H.
In times of difficulty, organizations often turn to consultants to get an outside perspective on their practices. Santa Clara Valley Medical Center (SCVMC), the public hospital in Silicon Valley was no different. Between 2007 and 2010, SCVMC hired a large expensive U.S. consulting firm to address the problem of patient flow- a ubiquitous and critical problem affecting most hospitals; however they did not achieve the desired effects.
Patient flow can be defined as the patient’s journey through the hospital, from admission to discharge. Good patient flow is considered to be a quick admission to the hospital, a smooth transition to the inpatient unit, swift and effective treatment, and discharge as soon as medically ready. Critical to patient flow is the availability of hospital beds. Without enough hospital beds, it is obvious patients cannot be admitted and cared for. Additionally smooth patient flow is critical to improving safety, quality of care, access to care, and the patients overall experience. Unfortunately, the small improvements achieved by the consultants departed with them when their time at the hospital ended.
In 2014, SCVMC was still struggling with patient flow, while at the same time they were seeing an increase in the number of insured patients with the implementation of the Affordable Care Act. As a result, SCVMC was frequently forced to divert ambulances to other hospitals because the Emergency Room was full. The Emergency Room was at capacity because there were no staffed hospital beds to admit patients. And there were no hospital beds available because there were inefficiencies in multiple areas beyond just the lag in discharging patients. Since SCVMC is the public hospital and trauma center for Silicon Valley, shutting the doors due to the hospital being full could be catastrophic. The physicians were overwhelmed with the volume of patients and other hospital staff members were burning out. There was little communication between departments and the staff was disengaged.
Internal Empowerment
Under the leadership of Santa Clara County CEO, Dr. Jeff Smith, and SCVMC CEO Paul Lorenz, SCVMC decided to look inward for solutions, instead of outsourcing the problem solving as was done in the past. Working with Stanford University Transformation expert, Dr. Behnam Tabrizi, they sought to bring about change in the medical center from the inside out- by investing in middle management. Instead of bringing in external consultants, they used an approach based on Tabrizi’s book, Rapid Transformation, an approach designed to engage the employees and to harness the collective intelligence of the people who do the work. The book’s methodology has notably been adopted by leading Silicon Valley and global companies, such as Apple, Google, HP, Verisign, etc. This approach is firmly rooted in the belief that the best innovation comes from the employees with the most intimate knowledge of the organization.
Build Trust Across the Organization
To create and maintain a culture of innovation, diverse cross-functional teams were established with over 80 participants from many departments. These teams, made up of physicians, nurses, social workers and others drew expertise from all across SCVMC and allowed for integrated problem solving. Much like the private companies of Silicon Valley, this SCVMC transformation team established a flat hierarchy where all participants are equally accountable and have an equal voice.
“It was important that we engaged all levels of frontline staff and departments to re-evaluate everyone’s role in the flow process in each of the sub-teams. In addition to redesigning how we communicated and planned patient care with nurses, physicians, therapy, care managers, respiratory therapy and medical social workers, we also engaged the support staff such as Environmental Services Workers and Transporters to improve their processes that are critical to improving flow” — Jill Sproul, RN, SCVMC Chief Nursing Officer and Transformation Sponsor
Through the teams efforts, it was revealed that past patient flow challenges had created a survivalist culture with minimal communication between departments. It became apparent in order to make this effort different than those in the past, the departmental silos and biases had to be set aside. By using multi-disciplinary teams, SCVMC was able to establish trust across disciplines and focus on innovation. The first task for these teams was to determine which problems should be tackled to improve patient flow. They created process maps, found opportunities for improvement, and identified necessary cultural shifts. Data mining was used to prioritize issues and to drive design making, as well as to maintain objectivity. Using such statistics to guide process improvement allowed change to be overall more impactful and further prevented subconscious bias from interfering.
Engage the Community
The second step for the teams was to create a roadmap for the future. Teams brought on new staff members whose expertise complemented their project and identified which kinds of data could mark their progress. The teams were empowered by the executive management to experiment and make changes along the way, instead of waiting to have a perfect long-term plan. One of the first successes was speeding up discharges by simply awarding a small prize to the resident physician teams with the best times each week. This change wouldn’t solve all of patient flow, but it represented progress and gave the hospital community the momentum and motivation to keep working. To maintain the culture of innovation, the teams met every three to four months to discuss their progress and learn from each other. As it turned out, different teams would often need the same things, such as more IT support, and thus “tiger teams” were developed for these projects to support all of the cross-functional teams.
It was discerned that the engagement of the hospital community was crucial to address a major roadblock to discharges that prevented successful patient flow. In order for a patient to be discharged, they must be deemed healthy enough by doctors (“non-acute”) and have a safe destination they could be discharged to. As the public hospital, SCVMC sees a number of patients who are homeless, who suffer from substance abuse issues, or have other behavioral issues. These patients are very difficult to discharge, even when healthy enough, because it is hard to assure they have a safe place to go. At one point, these non-acute patients who were healthy enough to be discharged but had nowhere to go were taking up almost 30% of the beds at SCVMC. To address this problem, a variety of departments had to come together to create a new care management process.
In an effort to reduce the non-acute rate to 7.5%, below their goal of 10%, physicians, nurses, social workers and others contributed. Importantly they achieved this goal by reaching out to and strengthening ties with community partners, external facilities, and health plans. A notable success of the new process was for a homeless patient who had been alternating stays at SCVMC and shelters in the area. By applying the new process, the staff at SCVMC were able to rehabilitate the patient, locate and reconnect him with his family in another state, as well as obtain insurance for him. This achievement showed the power of the transformation process to the hospital community and motivated more collaboration and innovation to improve patient care. As Jen Eng, MD, one of the flow leaders at SCVMC said, “Before being a part of this effort, I thought that doctors were the most important part of patient care. But now I realize the impact Therapy Services has too”. Victories, such as this one, enforced that the success of the hospital was dependent on the contribution and collaboration of all employees. This success encouraged SCVMC to continue work on the transformation.
Centralize Information
All of the efforts to improve patient flow culminated in the creation of a central Logistics Center in the hospital. The Logistics Center is comprised of multiple dashboards and programs including the Flow Accelerator developed by the flow team. The Flow Accelerator is a digital platform where each patient is coded as green (ready for discharge), yellow (waiting on 1–2 tests/consults etc. for discharge), or red (not well enough for discharge). The Flow Accelerator prioritizes the tasks needed to discharge the yellow patients which has increased bed turnover by decreasing the number of avoidable days in the hospital by 15% and increasing the percentages of discharges before noon from 15% to 40%.
By incorporating the Flow Accelerator, along with bed-tracking software and a real-time estimate of bed capacity, the Logistics Center is able to keep a high-level view of patient flow in the hospital at any given time. The Logistics Center is staffed by nursing supervisors, bed managers, transfer coordinators, and an assigned physician 24 hours a day, every day of the year. The implementation of the Logistics Center has decreased the time from a bed request in the Emergency Room to bed assignment by 30%.
The creation of the Logistics Center was cited as the top reason that SCVMC was awarded the status of HIMSS Stage 7- a healthcare industry designation recognized nationwide for excellence in the use of electronic medical record keeping to improve patient safety and outcomes. HIMSS Stage 7 is the highest level of achievement possible in the HIMSS model for hospitals, and only 5% of healthcare organizations in the nation have attained this status. Even more impressive is that SCVMC is the first public hospital in California and the second public hospital in the nation to achieve this status.
Lasting Changes
While the rapid transformation process improved patient flow and quality of care in a variety of quantifiable ways, the effect of the transformation on the hospital culture cannot be neglected. Because the public system has limited resources and is heavily unionized, the transformation relied on the engagement and empowerment of the hospital community. Despite a 15% increase in total hospital traffic from 2013 through 2016 the hospital was able to reduce the amount of time they diverted ambulances away from the Emergency Department by 50%. Without the excitement, willingness to work outside of normal hours, and commitment to providing a high level of care from so many participants, the improvements to patient care and flow would not have been possible. Santa Clara Valley Medical Center is proud of their accomplishments and hopes that their story can serve as an inspiration and roadmap to other teams striving to improve themselves and the services they provide.
Sanjay Kurani, MD is the Medical Director of Inpatient Medicine at Santa Clara Valley Medical Center and Assistant Clinical Professor (Affiliate) at Stanford University School of Medicine. He is the Co-leader of the Center for Leadership and Transformation Hospital Flow program.
Clifford Wang, M.D., M.P.H. is a hospitalist physician at Santa Clara Valley Medical Center and Clinical Associate Professor (Affiliate) at Stanford University. He was the former Chief Medical Officer and is now a Co-leader of the Center for Leadership Transformation Hospital Flow Program.
