Cleveland Clinic Florida Uses a Portfolio Approach to Improve Productivity

Kerry Major, MSN, RN, NE-BC

At the beginning of 2015, Cleveland Clinic Florida faced a capacity problem. The 155-bed multi-specialty hospital routinely ran at 92 percent capacity. More than a year later, occupancy has dipped to 88 percent, even while performing more surgeries. The hospital has become more efficient thanks to a portfolio approach to productivity improvement spearheaded by three leaders – Chief Operating Officer Ozzie Delgado, Chief of Medical Operations Fabio Potenti, MD, and Chief Nursing Officer Kerry Major, MSN, RN, NE-BC.

Nurses were a key stakeholder in the initiative to improve productivity. “As you are moving the patient through the system, nursing plays an integral part from the point of entry through transitioning the patient to the next point in the care continuum,” says Major. “This [project] never would have gotten off the ground without nursing input and buy-in as we are often at the forefront of new initiatives and processes.”

Streamlining operations hospital-wide

Cleveland Clinic Florida is in the midst of a $300 million capital project that will add more than 100 observation and inpatient beds as well as three new operating suites. While those additions will aid the busy hospital, the expansion isn’t expected to be completed until 2018. In the meantime, a multidisciplinary team took a hard look at how to improve productivity.

“We considered what we could do to help create capacity while maintaining patient safety, quality outcomes and a positive patient experience,” says Major. “We took a no holds barred approach and identified some key areas we could really drill down on.” Representatives from across the hospital – including leadership, operations, nursing, physicians and ancillary services – considered implementing changes in the following four categories:

• Emergency Room Capacity Management
• Surgical Operations Streamlining
• Transitions of Care
• Partnerships (with post-acute care providers, outpatient facilities and others)

With all the stakeholders around the table, the group considered all ideas. “Everything was on the table for review,” says Major. They prioritized strategies, choosing to implement ones that would yield the greatest results and put others on hold for later. Some of the changes that allowed for greater efficiencies were:

• Improved patient triage, staging and follow-up in the Emergency Department, which decreased unnecessary admissions
• Extended operating hours until 9:30 p.m. and leveled surgical volume, which helps alleviate logjams waiting for beds post-surgery
• Employed algorithms and analytics to better predict census and necessary resources, which allows the hospital to make better use of its facilities and adjust staff as needed

Contributions from nursing

Taking a closer look at one aspect – patient discharge – reveals the important role nursing plays in improved productivity at Cleveland Clinic Florida. “To get more patients in we obviously have to create capacity for them, so that means safely transitioning the ones we have out of the acute care space,” says Major. “So we decided to look at the discharge process as a whole, and our nursing team is front-and-center in that process.”

Among those who offered ideas on how to alleviate the discharge bottleneck were frontline nurses, nurse managers, case managers, the nursing operations manager and the bed allocation officer, who is also a nurse. After reviewing current discharge protocols and processes and discussing solutions, Cleveland Clinic Florida hired a discharge hospitalist whose workday begins at 3 a.m. to start the daily discharge process. The hospital also set new expectations for discharge, created a mechanism for nurses and case managers to discover any barriers to discharge and encouraged discharge planning between patients and caregivers from the time of admittance.

“Having nurses at the table when we made decisions helped them understand the impact of late discharges. They saw how it impacts many aspects of the hospital operations,” says Major. “Seeing the big picture helped them buy into making improvements.” In the past year, the average time of discharge has gone from mid-afternoon to late morning. That means more beds are available earlier to accommodate those patients recovering from morning surgeries.

Communication critical to maintaining efficiency

Cleveland Clinic Florida’s continued improvements in productivity can be attributed in large part to its communication strategies. About a year ago it instituted a daily operations huddle run by either a hospitalist or the chief of medical operations. A representative from every area attends, including but not limited to, each inpatient unit, the emergency department, radiology, lab services, environmental services, food and nutrition, physical therapy, respiratory therapy, case management, supply chain, quality, risk, facilities management and pharmacy. “Anybody who might impact our ability to have efficient patient flow is there,” says Major.

During the meetings, held at 9 a.m. Monday through Friday in a conference room, someone from each discipline shares information that could impact productivity, patient flow or patient safety. For example, environmental services might report staffing challenges that may result in a slower room turnaround time or pharmacy might share issues concerning medication shortages. Current and anticipated bed capacity challenges are also shared. “It ensures that everyone is on the same page coming out of the meeting and can plan for their areas accordingly so the impact on our processes and patients is minimal,” Major explains.

In addition, nursing holds three daily meetings – in the morning, afternoon and evening. Nurses discuss what they anticipate for that day and the next. How many surgeries are scheduled? How many anticipated discharges? They also consider staffing issues and any potential challenges for each unit.

The combination of solid communication and improved productivity measures has led to “an internal efficiency that allows us to hum through a really busy day,” says Major. “Everyone understands what we’re doing and why we’re doing it as well as the role they play in ensuring a successful day.”

Photo credit ©Russell Lee.