Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. Caring for about 800,000 lives in their region, Northern Arizona Healthcare is no stranger to challenges concerning patient flow and care orchestration. In this episode, Dr. Chuck Peck and Ben Sawyer are joined by not just one but two guests from Northern Arizona Healthcare. They sit down with Dr. Derek Feuquay and Jake Lansburg to discuss their care orchestration as a whole and how they overcome issues on access, throughput, and capacity. They take us deep into their process design and transformation to facilitate better patient movement as well as giving patients access to better care. From creating cultural change to accelerating the transfer process, having a phenomenal care coordination team, and turning data into information and insights, Dr. Derek and Jake cover a range of important topics to help you navigate these pressing healthcare challenges. Tune in and learn to better optimize care orchestration!
Listen to the podcast here
Optimizing Care Orchestration: Overcoming Challenges On Access, Throughput, And Capacity With Dr. Derek Feuquay And Jake Lansburg
For those of you that are regular readers, you know that over the last several episodes, we have shifted our focus away from the pandemic. We are spending some time on some basic operational challenges that I know everybody has been facing even well before the pandemic started. We are very fortunate. We have two guests from Northern Arizona Healthcare to talk about something that has been a huge challenge for almost all systems for years. That is the whole issue of how to optimize what I’m going to call care orchestration and focus on the issues of access, throughput and capacity.
We have two experts joining us. I’m excited to welcome them. I would like to welcome Dr. Derek Feuquay, who is the Chief Medical Officer and has been the Chief Medical Officer there since 2019. He joined Northern Arizona in 2009 as an internal medicine hospitalist. He has had some leadership positions since then. He was the physician advisor. In his position, one of the things that stands out about Derek is that he served as a leader and a role model for the physician community there for many years. I’m happy as a physician and internist to welcome him.
I also want to welcome Jake Lansburg. He joined Northern Arizona Healthcare in March 2020. He is the System Vice President for Care Transformation and Effectiveness with executive oversight of organizational, clinical performance, quality, safety, infection prevention, care transformation, improvement research data and analytics and care coordination.
Prior to joining Northern Arizona, he was an executive at Banner University Medical Center. He also is a Lean Six Sigma Black Belt. He was well-versed in process redesign and process transformation. I’m sure we are going to talk about that on the show. Let’s start with some basic information about what you all were facing in Northern Arizona in terms of throughput and access. What some of the things were that you started working on to meet some of those challenges?
Northern Arizona Healthcare is made up of two different hospitals and a standalone emergency department. One of those hospitals is a 270-bed Level 1 trauma center in Flagstaff and the other one is at a 90-bed facility in Cottonwood, Arizona. That is much more of a community hospital. We cover 50,000 square miles of Northern Arizona. We are the only Level 1 trauma center and tertiary care center in North Maricopa County, where Phoenix is at. We also care for about 700,000 to 800,000 lives in that whole region. We cover from the Utah border to the New Mexico border to the California-Nevada area, all across that Northern part of the state.
As you can imagine, when we take people from so many places, one of the difficult things is getting them back to those places after they come and stay with us. That creates quite a throughput challenge, especially since some of the areas we care for are impoverished. Getting people to come and pick up their family members, finding rides or even sometimes air transport for people to go back to where they came from can be difficult and causes some strong throughput issues through our emergency department.
Being the only regional hospital in Northern Arizona, with Flagstaff Medical Center being the only Level 1 trauma center North of Phoenix, it is important that we continue to provide the community and region access to great care. It is difficult when certainly there is no bed capacity, staff bed capacity or even physical bed capacity. The focus on patient throughput and movement throughout the system not only provides a better experience for patients but is safer for patients. It allows us to continue to serve the community that needs our care.
One of the things Ben and I like to do on our show is focus on some practical solutions that people can bring back to their organizations. It sounds like you are in a very challenging environment. You had a lot of obstacles and challenges that you were thinking about and had to overcome. I’m curious. Let’s focus on the throughput issue for a minute. We are going to get to the patient transfer process and work with physicians to try to capture as much of that area as we can. What did you identify as some of the major issues with throughput in your organization? What are some things you did to improve that situation, including technologies and other things in terms of integrating with other members of the team that helped you solve some of these issues?
Making it an organizational focus. As we embark on board-level initiatives, we have a pillar of clinical excellence providing high-quality, safe, patient-centered care. 1 of our 4 initiatives in 2023 board supported is around our throughput composite score. Our throughput composite score is made up of two different components. One is around reducing patient length of stay to appropriate levels. It is risk-adjusted based on acuity. We use a geometric mean length of stay percent measure. We are looking at discharging patients sooner from the facility.
The ED demand curve, you look at the number of patients that come in from the emergency department, the OR downgrades from the intensive care unit and what we like to accept patients who need us from the community through the transfer center, about 45% of our patient need happens before 1:00 PM. Only 35% of those patients that are discharged for the day end up leaving the facility before that time.
Daily, we are already starting at a disadvantage with a small backlog that compounds throughout the day, which leads to longer wait times for patients, excessive boarding in the ED and threatens our ability to take patients from our community that need our care. We have done many different things. We are partnering with every single department that touches the patient. Primarily nursing, our providers, hospital medicine and specialists. The most important is our care coordination team.
We have a phenomenal case management team throughout the organization starting initiatives that look at discharge planning on day zero. On the day of admission, we identify what the patient needs, the discharge plan and the backup plan should that original plan fall through. The secret sauce is getting the entire care team aligned around what the plan is, early identification of barriers, collaborating throughout the patient’s course of treatment and removing those barriers so we can get that patient home in a safe discharge. That is probably the first area of focus.
I love listening to Jake talk about this stuff. His expertise and efficiency are amazing. We joked that we were going to start taking him to mass with us so he can make the communion process more efficient. What he is talking about, which is important and something we are focusing on in Northern Arizona Healthcare, is leadership development. One of those things is teamwork and breaking down silos. He is talking about getting people to align across the organization.
One of the things you have to do if you are going to take on an initiative like throughput and length of stay is you have to get people like the hospitalists, the care coordinators, the nursing staff, the administration and specialists all on the same page. That is a tough thing to do. You have to do that through relationship building. That is something where Jake excels. Getting people to sit down in a room together, like our director of hospital medicine and our performance improvement experts, getting those people to talk the same language but more importantly, trust each other and trust what they are being told. We have achieved that through those interactions, listening, respect and influence.
What we end up with are people that can sit and work together well and feel that they are not in competition with one another to accomplish a goal. They feel like they are all rolling the boat in the same direction. They all understand why it is important for things like the length of stay and throughput to be high priorities at the organization. Not that it is not important because I’m a doctor and I will discharge the patient when I’m ready. It has been a big achievement.
Quick question, Jake. Most organizations struggle with the mechanisms to be able to pull all that team effort together. Could you share some examples with your multidisciplinary rounding daily or other examples where that team focuses on patient throughput as a priority and come together to help you accomplish that throughput performance you are talking about?
It is a team sport. Not any individual can do this alone and make a significant impact. Our initial efforts were we noticed our observation patient population, those patients with shortened length of days, probably less than 48 to 72 hours. We noticed that their length of stay was prolonged. We certainly had some opportunity there. Getting the different teams together, including nursing, hospital medicine and care coordination, was the core team that we started with the implementation of a closed observation unit. It is a dedicated physical area with twelve different beds for those observation patients.
We are creating a focused factory around an appropriate level of care to deliver against those quite aggressive length-of-stay goals. The care team meets twice a day. They are looking at barriers to discharge and evaluating patients’ discharge plans. The core teams are hospital medicine, care coordination and nursing. We need many other specialties in disciplines there, like physical therapy and diabetes education. It takes a village to deliver excellent patient care.It really takes a village to deliver excellent patient care. Click To Tweet
Even EVS, we have to make sure the rooms can get cleaned. One of the things that Jake did that was a nice thing in developing that observation unit is that when he brought all those people together, he gave those people the ownership of that unit. Jake isn’t the one or I’m not the one to tell them who gets admitted to that unit and what time they need to go. That was developed by the nursing managers of that unit and by the hospitalists who take care of those patients. The hospitalist who takes care of those patients on any given day regulates who comes to that unit.
The ER doesn’t get to send people up. They look at people and say, “You are an observation patient but you are going to be complicated and need skilled nursing. This isn’t the best unit for you because we are not going to be able to turn you over in the right amount of time.” That ownership for those people who run the unit is important because they fix mistakes along the way. They feel like they have buy-in on that building process.
One of the issues that every organization faces, at least that is what we have been hearing from a lot of our guests, is they have a huge amount of data but little actionable information. I’m curious. As you are coordinating all these people together in a room, I’m sure that there must be some dashboards or analytics that you use throughout the organization so everybody understands where that individual patient is in their care path. Could you talk a little bit about what you have developed there? Our audience is interested in understanding what some of the key metrics are that you are using and how you are getting it to everybody in the organization so they have a view into that patient.
To your point, data is one thing. You give a whole bunch of data to people. It is not all that helpful. People need the data turned into information. That information turned into insights to provide better care to patients. We have dashboards through hundreds of measures, both process and outcome measures. We have standardized measurements of what winning looks like.
The first step was getting everyone to understand what the key outcome measures are. What does the geometric mean length of stay percent even mean? If I don’t know what the measure means, it is going to be difficult for me to influence and improve that and in setting our goals around timeliness before 1:00 PM. It is our critical point throughout the day when we need a majority of those patients to be discharged.
First is helping people understand how these items are measured. What does winning look like? Once we have those outcome measures identified, what key processes do we want to be focused on that we think are going to impact moving that outcome measure? I’m a big fan of leading measures that tell us if the process is working. Give us an early warning sign if something is not operating or a system is not operating as it should before we encounter a big impact on the outcome piece of it.
We are looking at things like bed placement time, discharge order time, what percentage of orders entered before 10:00 AM, what percentage of patients are discharged by 1:00 PM and how quickly it takes from the discharge order to actual patient discharge. There is a whole other side of this around data helping to reduce unwarranted variation in care.
We are developing standardized care pathways for certain patient populations. I will take heart failure, for example. There is a plus or minus 3 to 4-day difference between some providers and how care is delivered for those patients. If we can narrow that variation right and shrink the curve, that will help reduce the length of stay by reducing that variation and add capacity back to the system.
Quick question on that, Jake. A lot of our readers talk about their EMRs, that they are data-rich but insight poor, which is what you are alluding to. Is this data coming from the EMR? How are you getting this insight that is helping you drive operations?
The data does come from the EMR. That is not where the information comes from. It is important to get these multidisciplinary teams. I’m a big believer that those closest to work understand what needs to be changed the best. We have people that do this type of work for 12, 13 to 14 hours a day. They can help take the data piece and turn it into meaningful insights. They know where they gave Lasix every day. They are also the ones testing hypotheses and saying, “If the diuretic dosing isn’t appropriate, we might see longer patient length of stays.” That closes coordination with our analytics team to help turn that and test those hypotheses to help derive those insights that will form recommendations for better care delivery.Those closest to the work understand what needs to be changed the best. Click To Tweet
We have talked a lot about technology and people. This can only be successful if everybody is on the same page. Talk a little bit about the cultural change that goes into this because you can wrangle everybody. As a hospitalist, I spent lots of time in multidisciplinary rounds addressing this. What training have you done to make sure that when everybody gets in there, they are all spending the right amount of time and what they are talking about? Have you incentivized people in their compensation? Sometimes we steer away from that because we are supposed to be on a mission but these are people’s jobs. We can incentivize them to perform appropriately in that.
The last question I would pose there is, where have you seen the greatest impact in a particular patient population or area? I bring that up because sometimes our readers think, “We are trying to boil the ocean. We have to fix everything. I’m going to see an impact on everything.” If you have seen it in a sub-segment, it has been very impactful. Start with the cultural change in that.
That is the thing we have worked very hard on. We had throughput or linked the stay committees for years. They never go anywhere. No one ever has ownership of the problem. It was like, “That is this person’s problem but he never looks at it globally and tries to accomplish it.” One of the great things that Jake has done here is he got the right people into the room.
The trick is, as you know, you and I both being hospitalists, it is hard to get the physicians to sit down in the beginning, look at that data and be open-minded to the data and ideas. That is a big part of that. Jake was talking about having the people who do the work, who are closest to work, help come up with the plans. A lot of times, people will feel, especially physicians or nurses, that was pushing this on them and making them do something that makes their workday harder.
We have worked very hard both ourselves and through our leadership development to sit down with those people and have them build relationships where they can influence one another, talk to one another, care about each other and make decisions that are going to impact the patient care as long as we keep them focused on that patient care piece. That is important.
Jake and I spent a lot of our time initially, almost being the referees between the analyst people and the physician or caregivers, trying to build those relationships where they could have conversations. Now they can have those meetings without Jake and me being there. That takes time. You have to develop that trust for that to happen and see some impact.
For example, we had one order that we put in. My wife helped get this initiative started. My wife is a transfer center director. She is a hospitalist as well. It is about a discharge readiness order we put in the day before the person goes. I always put it in after I see the patient ready for discharge. That tips the nurses off to do all the things that they need to do to get the person ready to go the next morning so they are not doing those things after the order has been put in for discharge. That has been very successful. We have seen that correlate with people getting out of the hospital earlier the next day. Little things like that at first, the hospitalists would say, “It is another order I have to put in the computer.” All they can see is that it helps run the whole system smoother.
The other thing I will answer for you is the incentive metric. We did something a little bit out of the ordinary. Jake can disagree. I don’t think he will though. We have several different specialists within our employed medical group with the same metric. Hospitalists, cardiologists, orthopedists and neurologists all had the same length of stay metric. It wasn’t something that was within their control. It was something that they all had to be aligned on and work together on.
For example, if I’m the hospitalist and I need to discharge someone and I’m simply waiting on that echocardiogram to get completed or I’m waiting on that neurologist to come back by and say, “Yes, I think this person can go,” everyone has the same metric. They are all tied together, which we think is an important thing in terms of getting everyone aligned.
It is critical for that alignment piece. It can’t just be hospitalists. Hospitalists have a big component in overall patient length of stay but they are also partnering with specialists and subspecialists. It takes everyone to move the needle in improving throughput and like Derek mentioned, getting cardiology. What is their role in the length of stay reduction? They might be able to provide their recommendations earlier or around earlier on the patient or focus on echo turnaround time reduction. Identifying those individual components makes up the larger picture for us to see better outcomes in a reduced patient length of stay.
Let’s get down to brass tack for a second. I will let you pick the period but could you share with the audience some of the results you have seen from the time that you both came and started this entire process to where you are? What people like to know was this sounds great but what happened to the length of stay? Where was it and where is it now? How have the outcomes improved? Has the quality been impacted?
I will preface that by saying that when we started this initiative, I don’t want to say COVID is over but it was during the tail end of the pandemic. Our length of stay was a disaster. We keep talking about the length of stay because it has such a great influence on throughput but our length of stay was an absolute mess. Part of that came from what I talked about earlier when I said our geographic location in the distance in which we have to get people home or get them to skill nursing is quite difficult. I will let Jake speak to the numbers. We have seen an improvement but still, we are not where we need to be yet.
From an outcomes perspective, we are focusing on, “Are we winning or losing?” From an inpatient length of stay perspective, we have been able to reduce around 8.5% over baseline, which is quite significant overall from an inpatient piece that puts us from around 137% GMLOS down to around 126%. Looking at the observation patients specifically and our baseline, which was coming out of COVID, was running around 50-plus hours for the OBS patient.
We are down to around 29 to 30 hours. We shaved almost 1/3 of the patient stay off. Your 0.2 around quality certainly is a point of pride for me. My other job is I get to do quality safety for the organization. I’m super proud to announce that Northern Arizona Healthcare, every quarter of the state, ranks our healthcare-associated infection performance. NAH was best in the state for a C. diff.
I had a point in asking the question and you proved that point. With all my consulting experience and working with organizations, I have tried to convince them that you can do all this and improve quality, not decrease quality. The other point is that people start these things, doctors, especially Derek, you will agree with this and Darren, immediate gratification is the name of the game. This is a marathon. It is not a sprint.
When you start working on this thing, you all have those impressive improvements but you didn’t get it from 137% down to 84% in a couple of months or a couple of years. This is a hard thing to do. Eight percent is significant. People need to understand that this is something that takes time and you have to stay in the process and you need commitment. I assume you guys would agree with that.
Jake will always tell you, “It is incremental change.” When he sets metrics or works with the physicians to set their quality metrics, he always makes them achievable. You are not going to go from 135% to 80% because everyone gives up. He does a nice job of setting those metrics to benchmarks they can achieve. That is crucial.
The other point you are making that I love, which was a hard thing for me to accept, is I still am clinical and I see patients multiple times a month but I also have my administrative role. Those are two different places to live. When you are a physician and someone’s sodium is low, I do some things, check a lab, see if the sodium is higher and I continue to get that instant gratification that you are talking about. You can do that quickly.
In the administrative world, which is where I will put this throughput in the length of stay initiative, those are marathons. You are right. You got to have a lot of endurance to get through those things and understand that it is a constant process. That is tough for doctors and nurses because we are used to getting information back, making quick changes and going from there.
The other issue that I found is being a physician, everything is one-to-one. Being an administrator or somebody like Jake, everything is one to end. It is all about teams. It is not about you and the patient in the room together. That is a big thing that you have gotten doctors to understand. This is great. We are getting near the end of the hour. I wanted to ask a question about your referring physicians.
Since you are working very hard on all these issues, you are doing it so that you can increase the number of patients that you can take care of that need your care. A lot of the other issues that our readers are facing is this idea of looking out the window and seeing patients and doctors referring patients past the front door of their hospital. I’m wondering. On the referring physician side, what have you done to simplify and accelerate the transfer process? You are in a challenging environment. That is a big issue even for people that aren’t in a challenging environment. What have you done in that regard?
We used to have a very unique transfer center process where we had an emergency physician that sat in the transfer center, would take calls from outside facilities, talk to providers and transfer calls to other providers. It was cumbersome. Our time to accept was very long. I wish I had the numbers. My wife has them but it is so much better.
What we did was revamp the entire transfer center. We took the physician out of the process sitting in the transfer center. We have nurses that sit up there. We have a single provider acceptance model that my wife has implemented, along with Darren’s help. It is working very well. My wife went to every single physician in the organization that accepts patients and worked with them on their criteria for single-provider acceptance. We have a great and simple, which is an important algorithm, in how we accept patients into the organization that can probably take care of 90% to 95% of people that come here.
To your point about referring providers, we do have a lot of them. I get messages quite frequently on LinkedIn from providers in outlying areas that thank me for the simplicity of the process of our transfer center and how nice our transfer center is. When Albuquerque, New Mexico, Phoenix and Tucson are out of beds, they still find care here in Flagstaff at our Level 1 trauma center. They are shocked that they are able to get it.
They thank us for how kind we are. They thank us for putting people on wait lists if we have to. Our transfer center is top-notch. It runs so well. It has a great reputation. The only thing we need is more beds. We are building a new hospital for that. Our time to acceptance went down by twenty minutes when we switched from having the physician in the transfer center nurse and single acceptance.
We should end on that positive note. We wanted to impart some very practical information that people could take away and think about. You have done that, which is great. Thank you so much, both of you, Jake and Derek, for joining us. It has been a great half an hour. I would like to end by asking Ben to take a second to talk about our next several episodes and alert the audience to what they might be knowing.
We are continuing with the practical discussion that Dr. Peck talked about at the beginning. We do have a webinar coming up on May 23rd, 2023. We will have Jake and Derek again because they will be panelists on that webinar. We are going to be discussing the broader topic of optimizing patient throughput, what are the barriers and what are the solutions. This was a little bit of a microcosm in that but you want to tune in for that webinar. Invitations will be going out through the Baldrige Foundation. Those of you that are reading should be able to receive that invite.
Thanks again. We will look forward to seeing you on May 23rd, 2023, Jake and Derek.
Thanks for having us.
About Dr. Derek Feuquay
Dr. Feuquay was named Northern Arizona Healthcare’s chief medical officer in 2019. Dr. Feuquay joined NAH in 2009 as an internal medicine hospitalist at Flagstaff Medical Center before becoming medical director of hospitalist medicine at FMC in 2011. In 2018, he became the NAH physician advisor. In each of his positions, he has served as a leader and role model for the physician community.
Dr. Feuquay earned his medical degree at the University of Arizona School of Medicine in Tucson, Ariz., and completed his internal medicine internship and residency at Oregon Health & Science University in Portland. Oregon. He earned his bachelor’s degree in business administration from the University of Arizona.
About Jake Lansburg
Jake Lansburg joined Northern Arizona Healthcare in March 2020. He is currently the System Vice President of Care Transformation & Effectiveness with executive oversight of organizational clinical performance, Quality and safety, Infection Prevention, Care Transformation and improvement, Research, Data & Analytics, and Care Coordination. Prior to joining NAH, Jake was an executive at Banner University Medical Center — Phoenix campus where he led clinical, operational, and financial improvements for the Academic Medical Division to achieve Top 100 recognition from IBM Watson and national recognition from U.S. News and World Report Top 50 specialties for five service lines.
Jake earned his bachelor’s degree in Biopsychology & Statistics from Arizona State University and his master’s degree in business administration from the W.P. Carey School of Business at Arizona State University. He is a member of the American College of Healthcare Executives and a Lean Six-Sigma black belt.