When you are located in the fastest-growing state in the United States, customers have a way of finding you—but can you boost your efficiency enough to serve them all without massive increases in your facilities and staffing? That was the happy challenge facing Texas Children’s Hospital, one of the top pediatric hospitals in the U.S. Its solution: Adopt a Microsoft Business Intelligence solution to find and resolve bottlenecks in the flow of patients through the hospital in near-real time. As a result, the hospital has reduced delays by up to 51 percent, shaving a full day off the typical hospital stay and making it possible for the hospital to see as many more patients in a year as it could if it had added and staffed another hospital floor. And because the solution relies on familiar Microsoft technology, it was easily adopted by the IT department and clinical staff.
Houston’s Texas Children’s Hospital was growing as fast as it could. It just couldn’t grow fast enough.
Fast enough, that is, for a state that saw its population grow by more than 20 percent over the past decade. As people streamed into Texas from across the United States, Texas Children’s Hospital not only grew–it grew smarter, adding facilities and programs designed to reduce children’s needs for emergency or inpatient care in the first place. For example, it opened a community pediatric hospital facility and expanded the number of its primary care pediatric clinics throughout the city. Now, it is preparing to open a hospital dedicated to prenatal care for high-risk pregnancies.
||No other hospital we know delivers this data to administrators on a 15-minute basis, the way we do with the Microsoft BI solution—that’s the ‘wow’ factor when we show this to other administrators.
Manager, Enterprise Applications, Texas Children’s Hospital
Still, sections of the hospital regularly went on “census alert”—meaning that they were operating at capacity. When that happened, additional patients could not be seen until current patients were discharged and their beds became available. These bottlenecks could create delays that were felt throughout the hospital, much as a traffic jam at one intersection can grow to stall traffic for blocks.
Once doctors had cleared patients to go home, it took three hours to actually discharge them. And then, it took almost two hours to get their beds ready for new patients. That in turn increased the time that emergency center patients waited to be admitted to the hospital by two or three hours, on top of a five-hour wait to be seen and treated by an emergency center (EC) doctor in the first place.
Over the course of a year, the impact of the census alerts was the equivalent of the hospital not admitting new patients for a month. Executives realized that improving the flow of patients through the hospital would reduce wait times and minimize, if not eliminate, the census alerts. Improved patient flow would free hospital resources to serve more of the pediatric population without additional facilities or staff. Improved patient flow could increase the quality of care and lead to saving more lives.
The hospital assembled a clinical team from throughout its various departments to investigate the issue of patient flow. That team identified key targets that required greater efficiency and developed measurements by which to evaluate progress, including the time from EC arrival to EC discharge, EC arrival to hospital admission, hospital admission to arrival in hospital room, pending discharge to actual discharge, and discharge to preparation of the bed for the next patient.
As part of this process, the clinical team identified a new challenge: The hospital lacked a consistent, comprehensive, and timely way to aggregate, analyze, and display patient flow measurements. This was a very practical challenge for the hospital’s staff.
“I’m one of the people responsible for assigning nurses to the EC and other areas of the hospital,” says Jennifer Sanders, Assistant Director of Nursing at Texas Children’s Hospital. “That was tough to do when we didn’t know what was happening in those areas. I spent too much of my time going through the hospital, trying to figure out where the problems were at any one time.”
What the hospital needed, executives decided, was a centralized business intelligence (BI) tool, accessible to all staff, that would provide data on and analysis of patient flow measurements. Another requirement was that data and analysis had to be provided quickly enough for administrators and others to resolve patient-flow bottlenecks as they were occurring. Next-day reports would not be of much use.
Some departments already used BI tools, although inconsistently and mostly for clinical research. The hospital considered using Business Objects reporting, primarily because the tool was included with the electronic medical record (EMR) system that the hospital already used. That EMR would provide most of the raw data for the new BI solution. But the hospital had concerns.
|Figure 1. The solution pulls information from an EMR system, processes it into |
reports and an analysis cube, and makes the information accessible to users
through a portal and dashboard.
“We’d have to roll out this BI solution to all users—which meant training 13,000 people in an unfamiliar system with which they were unlikely to be comfortable,” says Matt Sides, Manager, Enterprise Applications at Texas Children’s Hospital. “It meant staffing IT for another system and incurring the continuing management costs for that system.”
Time was also a consideration: The hospital had given Sides and the IT department just four months to put the BI solution into production. “This was uncharted territory for us,” says Sides. “We’d never tried to pull real-time or near-real-time data out of our multidimensional array EMR system. To simplify the challenge, we needed something with which our DBAs [database administrators] were already familiar.”
The hospital’s 13,000 workforce members—7,000 employees and 6,000 associates (mostly affiliated with Baylor College of Medicine)—were already familiar with a centralized tool to access, use, and share information: Microsoft Office SharePoint Server 2007. The hospital’s DBAs were already familiar with a powerful data management tool, Microsoft SQL Server 2008 R2 Enterprise. The missing piece was BI. Then Sides and his colleagues took a close look at Microsoft SharePoint Server 2010 and its service application PerformancePoint Services in Microsoft SharePoint Server 2010. “The integrated business intelligence tools in SharePoint Server 2010 were exactly what we needed. And it only made sense to continue with the same Microsoft tools that we already had and knew. We decided to use Microsoft technology.”
||I’m one of the people responsible for assigning nurses to the EC and other areas of the hospital. That was tough to do when we didn’t know what was happening in those areas.
Assistant Director of Nursing, Texas Children’s Hospital
In May 2010, four months after making that decision, the hospital went live with a preliminary version of its patient-flow reporting and analysis solution. It has been using an expanded, full-feature version since January 2011 (see Figure 1). That solution uses Microsoft SQL Server Integration Services to pull flat-file data from the EMS system every 15 minutes, convert the data to a relational format, and deliver it to a SQL Server data mart. The SQL Server technology also pulls data from a custom bed-management database built on Microsoft .NET into the data mart with the same frequency.
The data then flows into a Microsoft SQL Server 2008 Analysis Services cube. Microsoft SQL Server 2008 Reporting Services uses the cube and the data mart to create 36 graphical reports. Hospital personnel view these graphical reports on a patient-flow dashboard that runs in a SharePoint intranet portal. The portal is part of each employee’s personalized intranet home page and remains visible on select computers throughout the hospital (see Figure 2). Employees who want to explore and work with detailed patient-flow data do so by querying the cube and conducting “what-if” analyses using PerformancePoint Services and Excel Services in SharePoint Server 2010.
Three key groups of employees use the patient-flow portal, each in different ways. Most are employees, from janitors to administrative and clinical assistants, who need to know how well their areas are performing at any given time, so that they can adjust their individual efforts as required.
A second group consists of unit managers such as Sanders, who can make real-time decisions about reallocating personnel to improve patient flow. A third group consists of business analysts and executives who need to see an organization-wide picture of the data, to compare historical and current data, and to identify and resolve systemic issues.
Texas Children’s Hospital adopted a Microsoft BI solution based on SharePoint Server 2010 and SQL Server 2008 R2 Enterprise to treat more of the area population without having to build and staff new facilities. It succeeded. By using the BI solution, administrators now can make better and timelier decisions. The solution was also easy for the IT department to adopt, because it fit in well with the technology that the hospital already used.
Patient-Flow Bottlenecks Trimmed by up to 51 Percent
After less than a year using the full version of its Microsoft BI solution, the project to improve patient flow, reduce wait times, and treat more children successfully is itself a success. The average 6.6-day hospital stay has been trimmed by about 15 percent, or one day. Census alerts have been eliminated, which executives calculate has enabled the hospital to see as many more children as it could if it had added and staffed a new hospital floor.
|Figure 2. All 13,000 hospital workforce members have access to patient-flow data |
through the SharePoint intranet portal, here showing EC arrivals per hour.
“Our mission is to treat sick children,” says Sanders. “We want sick children to go to the right area of the hospital, get the right treatment, and return home as soon as it’s appropriate. By using the Microsoft BI solution, we’re more efficient and effective at this—seeing more children, providing full access to care, and maintaining the quality of care, without expanding the hospital or staff. There couldn’t be a bigger benefit than that.”
The hospital has eliminated census alerts by minimizing potential bottlenecks—by 19 percent to 51 percent—in all of its key measures of patient flow (see Figure 3).
The hospital has achieved these reductions while keeping a careful eye on the quality of care, to help ensure that none of the hospital’s new efficiencies has come at the expense of its core mission to serve children. Clinical outcomes such as infection rates are closely monitored. So is a measure called “bounce-back”—the measure of how many patients return to the hospital with the same complaint after discharge. These measures confirm that the hospital is seeing more patients and operating more efficiently while maintaining its high level of patient care.
|Figure 3: Key patient-flow measures, showing improvements with the use of |
the BI solution.
“Our efficiency improvements in no way affect the treatment that our patients receive,” Sanders says. “Patients are only moved, say from the EC to a bed, or discharged, when a doctor says the patient is ready, based on medical criteria. Our patient-flow procedures only become relevant in implementing the doctor’s instructions.”
Data Updated Every 15 Minutes, Spurring Better, Timelier Decisions
Better data, by itself, doesn’t produce the results that the hospital is now seeing. What does produce those results is the use of data to make better and timelier decisions. Hospital administrators are making those better and timelier decisions by taking advantage of the near-real-time, updates produced by the system every 15 minutes, and by using the highly intuitive dashboard, which is based on PerformancePoint Services and hosted in the SharePoint portal.
“No other hospital we know delivers this data to administrators on a 15-minute basis, the way we do with the Microsoft BI solution—that’s the ‘wow’ factor when we show this to other administrators,” says Sides. “Most institutions deliver this data to administrators the next day—when it’s too late to do anything with it.”
||The information I need is right in front of me on the SharePoint dashboard. Instead of trying to figure out what the problems are, my job has become trying to figure out the solutions.
Assistant Director of Nursing, Texas Children’s Hospital
Administrators make decisions on the basis of this information to address both temporary and systemic issues. As an example of the former, Sanders uses the patient-flow data to note when specific measurements in her areas exceed approved thresholds and to adjust staffing levels until the measurements again fall within approved parameters.
As an example of addressing systemic issues, Sanders noted that it was consistently taking a relatively long time for patients to transfer from the EC to one of her units. Investigating the workflow process, she discovered that the staff was relying on a push model in which EC nurses waited for a call from the unit before they took patients there. She and her colleagues developed a pilot test that changed the process to a pull model in which nurses in the unit retrieve the patient as soon as a room is ready, minimizing the EC wait. The preliminary result: transfer times have declined by 42 percent.
That is not the only measure that has declined for Sanders—so has her time spent walking around the hospital to get a sense of the problem areas at any one time. “My work is much more data-driven with the Microsoft BI solution,” says Sanders. “The information I need is right in front of me on the SharePoint dashboard. Instead of trying to figure out what the problems are, my job has become trying to figure out the solutions.”
Familiar Technology Adopted Easily
Meanwhile, the Microsoft BI solution has fit easily and cost-effectively into the hospital’s infrastructure. “Because this solution is based on SharePoint Server and SQL Server, we already knew almost everything we needed to know to make it work,” says Sides. “We didn’t have to hire a consultant to design and build this, and we don’t need additional people to manage it. We can be flexible in how we staff it, because our IT staff already understands .NET. Spinning up a new database instance is a familiar task in our organization.”
“While we went with what we knew, the BI capability in SharePoint Server 2010 gave us the opportunity to provide value to the organization at every level,” says Sides. ”Now, that's a cool feeling.”
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