BG Final Project Presentation GCU

Hi, my name is Brian

Geman and this is my final project

presentation at Grand Canyon University Nursing,

674 leadership in health care systems.

Practicum

February 14th, 2024.

I'm completing my practicum at Houston Methodist Clear Lake Hospital in Houston,

Texas.

So I'll start out by telling you a little bit about the hospital

that I've been

uh

completing my practicum in

Houston Methodist.

Clear Lake Hospital is a 178 bed nonprofit Faith based organization

with at least 500 physicians and 800 employees.

It's part of the Houston Methodist system,

which is comprised of eight hospitals and hundreds of

clinics and freestanding emergency rooms in the Houston area.

The Houston Methodist Organization mission

is to provide high quality cost effective health care

that delivers the best value to the people we serve in a

spiritual environment of caring and association

with internationally recognized teaching and research.

I've observed everyone in this hospital living these values every day.

They truly seem to believe in

uh being honest at all times and acting in an ethical way at all times,

employees provide emotional spiritual,

ethical care to patients families and each other.

In addition to medical care,

accountability is also a major focus for everyone

and they treat

each other and everyone they encounter with respect.

It's not only expected but demanded

the hospital and all its employees always do their best to be

a model to all health care workers as well as other entities.

Uh This hospital is

very well respected in the community

and and many uh

other entities try to emulate them.

My project goal align goals align with

the mission and vision of the organization because

it is to provide unparalleled care to the community.

My project seeks to improve processes that will

reduce the unnecessary time patients spend in the hospital

which may lead to further complications and decreased outcomes

every year at Houston Methodist Clear Lake Hospital,

senior leadership sets top level improvement goals for the hospital.

One of these was to improve length of stay.

Now, this can't be a challenging task

uh but it's also interesting and rewarding if you can make that happen.

So I chose to work on this as my goal.

My first step was to conduct a needs assessment.

Now,

the purpose of uh conducting a an organizational needs

assessment is to evaluate the goals of the organization

and try to determine what it needs to achieve those goals.

There are three steps in conducting

a needs assessment

which include first the initiation step

which identifies anything that might limit the project.

What I found here

was that there was not much excitement for change

um within the hospital or case management department.

Um They had gone through several leaders in the

past few years and so the morale was low.

So I knew it was gonna uh take some time and a little bit of

uh proof

of improvement to get the buy in from the staff.

Uh The next step was data collection and analysis.

Now, this was when data is collected and analysis of political,

economic, social and technological factors is considered.

Um

it also involves evaluating the organization's strengths, weaknesses,

opportunities and threats.

During this phase, I found that the utilization review,

nurses were very seasoned and experienced,

but there was no standard workflow.

This meant that everybody was doing things their own

way which may or may not have been effective,

but there was no oversight at all.

I also determined that criteria was not being applied correctly

and there's there was little communication with physicians.

The final step in this process is providing a summary of the findings

with recommendations

and I presented my findings and

recommendations to my preceptor and senior leadership

who quite honestly were

really uh

un

unfamiliar with the case management world. I found and kind of shocked that the

uh disarray that the department was in.

They were supportive of my recommendations and they did agree to move forward.

Uh The goal that is

set forth by the senior leadership team for the

hospital is uh 4.1 days for patients and inpatient status

and 24 hours or less for patients and the observation status,

I shadowed

utilization review nurses to observe their processes

and look for opportunities for improvement.

I went to most multidisciplinary rounds when I

was I observed seemed inefficient and somewhat ineffective.

It amounts to not much more than a nurse reporting out on their patients.

Now, during my research,

I found that early identification of barriers

can help reduce link to stay in hospitals

which in turn leads to better outcomes.

There is little to know

discussion about the barriers or the geometric mean length of stay or GML OS

in these multidisciplinary rounds.

Uh The GML OS is a number assigned to a diagnosis set by the Centers for

Medicare and Medicaid Services or C MS that is designed to show how long

a patient should be in the hospital for a diagnosis based on best practice.

My observation was that there

is a lot of disorganization and very little consistency.

There's also very little follow up on anything.

So the goals of this project were to reduce the hospital length of stay,

improve throughput and standardized processes.

My focus has been on improving,

standardizing the processes and I felt this would

allow the UR nurses to get a routine down

that would allow them to become consistent with the way they review charts.

It would also allow

uh

and as assistance and accountability. Uh as chart arts were to be introduced.

Um My goals were to reduce the inpatient length of stay year over year

and

reduce the observation hospital length of stay

to 24 hours or less.

I use the hospital goals of inpatient length, the stay of 4.1 and obs

or observation

to be

at or below 24 hours. As a guideline,

I use the reporting system used at Houston Methodist called Tableau or VIS

to identify the baseline length of stay from

the time

of starting the project through implementation.

The project began in October of 2023 and ran through January of 2024.

Following each month,

I ran reports showing the final numbers for October through December

of 2022 and 2023.

This system is one month behind in reporting so I

couldn't run a report for January as it wasn't available.

But what I found was that the inpatient length

of stay did decrease in the month of October

remained about the same in the month of November

and then decreased in the month of December.

When compared to the previous year,

you can see in the charts below with the inpatient length of stay for 2022 October,

they were at 4.4 October of 2023 4.2 November

of 2022 and November of 2023 that remained at 4.3

and December of 2022 was at 4.7 followed by December of 2023 at 4.5.

Um

When we look at the observation metrics, which is the length of stay in hours,

uh, for October 2022 they were at 42.8 hours versus October 2023 38.6 hours.

November 2022 was at 43.8 hours

compared 2023 at 40.4. And then December of 2022 at 44.2

and had a slight uptick in December of 23

at 45.8 hours.

My interpretation of this data was that

the changes implemented are working

but they may need some adjustments

during late January.

Uh I relooked at the new processes with a focus on observation

patients since this was the metric that had risen in December.

When I re evaluated the UR process, I found that the urrns were not always observing

the uh C MS to midnight rule which allows physicians to admit patients

to inpatient status when they feel patient will medically

require more than two midnights to stabilize or treat.

Also found that they were not escalating cases to the physician advisor

for review, possibly leading to cases that

cross the 24 hour threshold,

uh not being converted to inpatient when they may have been appropriate

to help address these issues. I created dot phrases in, in the EMR Epic

uh for the UR nurses as well as the providers dot Phrases are

a way in epic to make premade phrases that can be added to documentation

uh in the

position, progress notes or the

uh progress notes of the UR nurses.

Uh Now these allow the user to have a standard documentation for recurring issues.

As part of the urrn process. I asked them

to reach out to the physicians when completing their

initial review of the charts on Medicare patients,

uh both traditional and managed care

and ask the

uh physician if they believed it would be me medically necessary

for the patient to cross to midnight and document the conversation.

I also educated the hospitalists

um uh on the use of dot phrases uh stating they expected it

to be medically necessary for a patient across to midnight and then document why

also as a part of the standard workflow for Urrn si

asked that all patients remaining more than 24 hours be escalated

to a physician advisor for a review.

And since implementing these processes,

uh we have been seeing a decrease in observation

hours uh

currently for the month of February uh at running at about 21 hours average.

When I talked to the staff about making changes, they were skeptical.

Um they stated

many changes have been tried over the years, but few stuck

and they were pretty reluctant to give it a try.

But I explained my background in utilization management over the years

and asked that we work together to try some new processes.

Um I presented the standard workflow

I was proposing and asked for input.

Uh We made some minor adjustments based on

their suggestions and then we implemented the process.

Um After a short time, I began hearing feedback from some

of the nurses that they enjoyed the standard process and felt

like it was improving their skills as a ur nurse.

Now, organizations are always trying to improve

by reviewing processes and policies that help maintain positive outcomes.

Uh Multiple disciplines have been involved in identifying the barriers,

changes in implementation

during this project.

Uh a written standardized process was put in

place to sustain the utilization management department.

Uh This process will be reviewed periodically by the director of case management

and updated as needed, but no less than

annually,

monthly data will be collected and reviewed to evaluate

year over year performance to help evaluate continued effectiveness.

One of these things

being influential, uh what

uh

that is has was a goal of mine. Um

you know, they must be able to partner with others and convince them that they

following them will lead to a better outcome through acting certain

way or forming a function that may not have occurred otherwise.

And this was very important during this project because I needed them to

buy into this in order to get them to give it a try.

One of the goals I set for myself in the practicum

is to get better understanding of how to organize

and implement a new project effectively.

I do feel like I achieved this goal with the help of my preceptor,

she was able to help organize steps and focus on what was important.

The a onl competencies I wanted to achieve included

holding myself and others accountable.

Um by learning to do this,

I've been able to achieve high quality and

cost effective outcomes by reducing length of stay.

Another was learning from challenges,

setbacks

um

and failure as well as successes.

Uh There were setbacks during this project such as staff,

not always following the new processes,

but I learned to keep bringing it back to how it

affects the team and the hospital as well as the patients.

And eventually the staff started embracing it,

then learning to improve my skills

of representative nursing in the boardroom or CC suite

has been one of the biggest challenges and blessings of this project throughout.

I've had multiple discussions and presentations with the C suite

which has boosted my confidence,

finally acting as a change catalyst and being open to change

and new information has taught me to accept new things, be open to other ideas.

When I'm trying to bring about change

by remaining open, other people feel empowered

to offer suggestions which makes process stronger and more effective.

I learned so many things. During this experience,

I learned to be flexible and always have a backup plan for when things go wrong.

I learned how to bring people back to task when they stray and

that people tend to try to revert to old ways when they're stressed.

So it's important to, to bring them back.

Also how important it is to keep people engaged.

Because if they're not engaged, the plan goes off course,

then it becomes difficult to get it back on course.

And then finally, I learned to keep evaluating the plan and make changes as you go

when something isn't working.

Because if you wait until the end, it becomes difficult to

uh get everyone on board and becomes overwhelming.

Overall,

it's been a great experience that I believe has made a meaningful impact that

is sustainable for the long term.

Thank you and

good night.

BG Final Project Presentation GCU

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