Case Study: Urban ED Process Drives Design

Case Study: Urban ED Process Drives Design A Deeper Look As Emergency Departments continue to serve a variety of roles in their communities, those in urban areas feel the pressures of both tertiary care and large numbers of underinsured patients with basic medical needs. Understanding the unique factors that each facility faces should drive solutions rather than national benchmarks or averages. Using predictive analytics and simulation modeling, we help each client develop the best solution for their situation.

Process-Led Design EMERGENCY DEPARTMENTS

PROCESS OVERVIEW

CHALLENGE

Before we consider architectural solutions, we design the process. In this case, Lean

An urban academic medical center

data-driven decisions guide our work. When appropriate, we employ simulation modeling

focused on pediatrics sees more than 85,000 visits each year in their emergency department. Designed 15 years ago, the

improvement work had been underway in the Emergency Department. Rapid testing and and predictive analytics to help clients make important early design decisions with clarity and certainty.

segregated pods and small triage area limit

The group had reached a threshold they believed needed to be overcome with an integrat-

flexibility and result in long lines and unsafe

ed process and space configuration solution. We were able to leverage existing through-

conditions.

put data to rapidly build a simulation model.

SOLUTION Through process mapping and discrete

Implementation Methods:

event simulation, a multi-disciplinary team was able to test alternate patient flow approaches to identify the optimal balance of process time and staffing resources to ensure consistent success.

•

Simulation

•

Process Mapping

•

Observation

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CNMC Current ED

ACUITY 1- Resuscitation 2- Emergent 3- Two + Resources 4- One Resource 5- No Resources TOTAL

85,000 visits Washington, DC 35% Fast Track Acute Treatment

Arrival & Initial ESI Check In / Triage

Security: Check ID, issue security badge

Assessment

Registrar: Name, DOB, SSN RN: quick assessment, complaint

1.5% 9.6% 30.4% 45.9% 12.6% 100%

Diagnostic

ED Physician: assessment, orders, treatment, discharge/admit decision, bedside registration

Security

PERCENTAGE

Admission

Registration Bay

RN: full assessment

Discharge

ED Physician: assessment, orders, treatment, discharge/admit decision 3 Minutes

73 Minutes

7 Minutes

175 Minutes 8 Minutes

15 Minutes

6 Minutes

20 Minutes

Acute Care

Assessment

Wait

Check in Triage Fast Track

Security

CURRENT CONDITIONS Time was of the essence. Check-in lines were long and creating unsafe supervision conditions in the waiting room. Door-to-Doctor times were longer than acceptable for some patients. Length-of-Stay was much longer than national markers.

Patients and their families were waiting at every step in the process.

The care of emergent pediatric patients is complex. Rapid decompensation and non-specific symptoms make any unsupervised wait dangerous. In an effort to

We were able to reduce wait times to less than five minutes for 99.02% of patients

gain as much information as possible, a two-step triage and assessment process was in place. Protocols could be started early and providers knew that patients were evaluated in detail even if they had a long wait. The unintended consequence was a bottleneck at assessment.

To combat the problem, the providers felt a redesign of the arrival area was necessary in conjunction with process changes to combine some existing care steps and reduce patient moves. While this seemed like sound logic, we were concerned the root cause of the problem might be deeper. Together, we conducted an eight-week process-led design study to understand the current condition and develop a sustainable future state model.

Allowing every staff member to work to the top of their license improves care.

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Implementation

DATA Using data the internal Group already collected, we developed a simulation model to test the implication of process decisions on overall throughput and resource needs. We created a dynamic tool that allowed the team to change the variables during our future state design meeting. This real time feedback allowed quick consensus and decision making about the ideal future state.

It became apparent through simulation that combining triage and assessment would slow down the system further and re-

The Lean Group appreciated the simulation exercise and how it brought to light that simply combining triage with assessment wasn’t their best solution. Fewer patient moves didn’t necessarily improve care.

Focusing then on reducing overall length- of-stay (while still

quire a high number of triage nurses to handle peak volumes.

attempting to reduce patient moves), the group instead moved

The providers felt it wasn’t the best use of so many high-

initial contact to a more conventional triage. This allowed them

ly-trained pediatric emergency nurses to be tied up in triage.

to quickly register and evaluate the large volume of patients

# of Patients Waiting

assessment to the bedside and reduced the length of the

they see each day with wait times of less than five minutes for 99.02% for all patients.

FUTURE STATE Through process redesign of security, registration and checkin, and the shifting of the nursing assessment to the bedside, patient throughput could improve by focusing on the key information at each step. Through simulation we determined that adding one additional registrar reduced overall wait times and allowed two nurses to return to bedside care within the current staffing model.

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\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ After robust process design, it was time for architecture to sup-

Who We Are

port it. Shifting to a more traditional triage approach left some

ARRAY-ARCHITECTS.COM

providers concerned about waiting room oversight. Through continued process-led design, we developed a one-way flow model that moves patients to sorted waiting areas that can be overseen by clinical staff immediately following initial triage.

This arrangement also allows the triage nurses to maintain visual oversight of the main entry.

We Are Healthcare Architects We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most.

process shifts in real time pending census. Registration lead-

This focus makes us leaders in our field. There’s a degree of compassion, empathy, and sensitivity that goes into every project that we touch. It’s designing a nurse station with sight lines to every patient. It’s building a Behavioral Health facility without corners, so that patients are safe. It’s translating the operational needs through the technical details to fine tune the lighting system in a neonatal unit so caregivers can match the lighting to each baby’s stage of development. It is a deeper understanding, honed through relationships spanning

ership can support front desk staff through their direct location.

decades.

No process is perfect. This configuration allows for some key

Additionally, nursing leadership can implement a pivot nurse pre-sort process if volume spikes unexpectedly. The front desk and triage area was purposely designed to support a flexible staffing model that can evolve over time.

Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.

Array’s Knowledge Communities We believe strongly in sharing our expertise and knowledge with others. We invite you to explore each of our thought leaders and share your thoughts with the healthcare design community.

Click here to visit our blog.

SUMMARIZING CONTINUOUS IMPROVEMENT Our core mission is the same as that of our clients, improve the quality of our work, increase our efficiency, and motivate our staff to reach for success. At Array, we are establishing a culture of continuous improvement at all levels of our organization. We seek to empower members of our team to be agents for good change. We have re-designed our design process using Lean as a foundation for a unique Process-Led approach that better meets the needs of today’s healthcare organizations.

We believe the transformative improvement that leading health systems, who have embraced Lean and other improvement approaches, have achieved is equally applicable to architecture.

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