Utilizing TQM and CQI prinicples in establishing a Type 1 observation unit in a comprehensive cancer center.

Abstract

96 Background: CMS defines Observation Services as outpatient care ordered by a physician and provided in a hospital bed to determine the need for inpatient admission or discharge. Recent CMS rules on Observation stay and 2-midnight rule has created confusion amongst Medicare beneficiaries, providers and hospitals. Two-thirds of US hospitals deliver observation care without using an observation unit. Review of our hospital observation care and a survey of Cancer Centers within the Alliance of Dedicated Cancer Centers revealed that observation care was provided in a bed anywhere in the hospital with unstructured care provided at the discretion of the treating physician. This leads to less favorable outcomes compared to protocol driven and closed observation units (Type 1). Methods: Plan- Institutional stakeholders consisting of administrators, hospitalists, ED physicians, case managers and nurse managers developed an observation services guideline policy and project team. Do- pilot initiated with ED admitting Observation patients to dedicated hospitalist providers and unit. Order sets were developed, education and staff training was provided and target start date set. Baseline and performance measures were developed. Study- impact on ED flow, admissions, ED length of stay, provider satisfaction, diagnoses, patient case-mix, and financial costs. Act– Implemented changes and lessons learned from pilot Results: Before implementation of pilot less than 10 patient per month were placed in observation status (Sept 2011- Aug 2012). After pilot average of 30 patient per month were initially placed in Observation (Sept 2012-April 2014). Approximately 73% of patients placed on observation are discharged and not admitted. Observation counts for approximately 25,000 dollars in professional charges per month. ED LOS decreased to less than 6-hours. Patient satisfaction and ED provider satisfaction scores have improved. Conclusions: Majority of Observation patients are not admitted thus avoiding the higher cost associated with inpatient stays with resulting cost saving. ED wait times have improved leading to less over-crowding with ED physicians having time to see more patients.