Case Study: Improving the ED Patient’s Experience A Deeper Look In communities with limited choices, emergency departments serve many roles. Understanding the unique needs of a facility and its population are critical to developing the best solution. One size no longer fits all. We employ Lean Assessment and Design strategies to help each client focus their resources to achieve the most improvement.
Modernize and Upgrade CHALLENGE A fractured check-in and triage process that evolved over time left patients waiting in long queues, sharing private information in the open lobby. Safety and length of stay concerns prompted Array to suggest a complete throughput analysis before developing front door renovation solutions.
SOLUTION
PROCESS OVERVIEW Our Rapid Lean Design Events (RLDE) are geared to help clients quickly assess their current condition, map out patient flows impacted by the process, identify areas for improvement or streamlining, and then establish an ideal future work flow. This future work flow is the critical first step in creating a viable and sustainable project. The RLDE is a swift and targeted multidisciplinary workshop often consisting of two or three sessions. When appropriate, data is collected between sessions to better focus improvement activities.
Implementation Methods: Observation & Current State Mapping • Data Collection •
After careful data collection and process analysis an improved future state process was developed and implemented with only minor space reconfigurations. The facility was able to test the process in their current department to be sure it would drive improvement before expending capitol dollars.
•
Future State Mapping
•
Develop the Road Map to Implementation
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We were able to redesign their process without redesigning their space.
CURRENT CONDITIONS A community hospital serving a large indigent population sees over 57,000 visits a year. While their facility was expanded and redesigned in 2004, the physical space and its care model were no longer serving the needs of the community. Attempts to speed care time led to additional clinical steps at check-in that created difficult privacy situations. Silos between registration and clinical providers (software and staff) compounded the gaps and duplication in information gathering. While the ED used a traditional fast-track model, all patients were screened identically through traditional triage. Efforts to shorten stays for low acuity patients were wellaimed, but the non-standard work caused unpredictable delays at triage as well as patient dissatisfaction. Facing the same economic pressures as all emergency departments, the hospital wanted to offer urgent care style services within the ED and improve their ability to funnel patients to the most appropriate provider, while capturing payment at the appropriate time. Through the analysis of current state data and a careful review of emerging care models in other facilities, we worked with a multidisciplinary stake holder group that included providers, administrators, volunteers and supporting services to develop an improve future state that could leverage the existing architecture.
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case study: ED process redesign | PAGE 3
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Implementation PEDIATRIC VOLUME= 10,000/yr
IRMC ED Arrival
Outpatient Pavilion entry causes confusion; safety issue
No consistent person/role to call
CURRENT STATE MAP 5.22.2014
ED LOBBY-SECOND FLOOR
ED DOOR/ FRONT DOOR/ OPP DOOR
LEVELS ACUITY * Collect # of patients that are repeat = _____________
Unassigned = 2.9%
* # of Patients discharged from Triage = ___________
0=0.1% 1=0.4% 2=20.0% 3=58.4% BACKER ACT/ PRISONER/ INJURY
4=16.6% 5=1.6%
RAPID RESPONSE
MID LEVEL & TRIAGE RN PROXIMITY IS GOOD
57,000 VISITS/YEAR
AMBULANCE LOW ACTIVITY
LESS SEASONALITY THAN PAST YEARS
Triage 2 Station Room has no privacy for patients
157 PATIENTS/DAY RECENT TREND
Emergent Distress
CURRENT CCTV CAMERA VIEWS DRIVE
Arrival • Patient presents at ED entry • If needed, staff brings a wheelchair to car
Medic at front desk steps away to do transport or EKG leaving desk w/o clinical team member
Wheelchair storage not as close to door as possible
No security monitor in Triage
Name DOB Scan Photo ID Chief Complaint Do they have an MD?
No way to track patients who arrive but don’t return clipboard
Verbalizing chief complaint has privacy issues
Chart to Triage
Return Clipboard
Vitals if Medic
• Patient gives clipboard to registrar • Registrar creates an account and checks existing acct. +/- 2 min • Ask have you been a patient before • Ask for SSN if can’t find record (not often) • Print labels • Arm band patient • Paperclip check in form and labels and give to Medic
• Sometime during quick registration • BP, Pulse, Respiration, Weight/Height (ask only) • Ask chief complaint • Visual Assessment
Not everyone knows to fill out clipboard
Mass of patients crowd desk with clipboards
Privacy Issue
Triage (+- 2-3 min) • Vitals if not complete • Review chief complaint • Review Symptoms • History • Med rec if volume low • Suicide screen • TB screen • Begin protocol if no room available • Call charge RN to assign room • Labs only if protocol started • Sometimes to Xray/ orders if in protocol
Wait
EKG • Chest pain patients • Medic does EKG • EKG walked to MD for review
Length of quick registration can delay Triage documentation
NO MEDS IN RN PROTOCOLS
New requirement to list admitting Dr. at time of registrastion causes longer accounts creation and its corrected later
No PC in rooms
Room
• Medic places chart in plastic bin or gives to RN
POPULATE TRACKING BOARD
(ALL ON CLIPBOARD)
Medic not always at front desk
Wait
• Call to assign patients to rooms for bed side triage if rooms are open
Quick Registration • • • • •
Might delay flow
Triage RN Calls Charge RN
• Immediate Triage Assessment • Registration comes to Triage Room or get info from family
CURRENT STATE
No minor care waiting
* Registrar until 11pm * Medic until 7pm
* Security
* = Not 24 Hour Coverage
• Bedside Triage if room open Bedside Reg does not always occur before visit ends
BEDSIDE REG.
Lab/ Xray/ Mid-Level Holding • Triage 3 as a holding room • Used as sub wait
Some visitors wait at check in desk, but only needed to see a volunteer
ED ENTRY
Volunteers • Provide Information to family • Transport (on tracker or via phone) • Clinical Setup • Goal 2/day • To assist staff (if not available, the RN or Medic transports)
Discharge
Wait
Registration Booth
Mid-Level • Eval patient • Treatment • Order Meds/Tests
Staff notes that not having a constant security presence is a danger
Minor Care Charge RN has no visual oversight of Minor Care Room Status, but responsible for Room Assignments
* Volunteers 9am-9pm 7 days/wk Triage RN * Triage RN * Mid level * Phlabotomy * Medic
* Need Data on throughput in part of bedside triage
Security at ED is a roaming position. Not always at desk
Minor Care & Mid level RNs
• Dedicated midlevel staff & RNs MInor care also now sees patient that are level 2 and going to main ED
Concern over to discontinuation of badging
Security • • • • •
Not stationed in ED Monitor back at position No longer badge visitors Transports 12Hr coverage (Sheriff covers other 12 Hrs) • +- 25% seated in waiting room (might be less)
Volunteers disconnected from other staff
No badge for visitors makes access to acute area tough to monitor
created for each client and tailored to their specific current state
IRMC Emergency Department Data Collection
After observing the process in action,
Date: we Patient worked #:
with a multidis-
TIME ciplinary team including nurses, patient care techs, registration
Patient Arrives Registration Complete
For one week staff tracked the overall process steps as a rep-
Notes:
clerks, physicians and department leaders,ESI toLevel? map the current state process and identify opportunities for improvement. 1 2 3 Begin Vitals Vitals Complete DATA
4
Wheelchair necessary?
process flow.
resentative sample of patients moved through the system. This 5
Y / N
information was then overlaid on the current state process map to complete the picture of the existing system and its pain points.
ABegin variety of data sources were used to analyze the current state. Vitals completed during registration? Triage
Both the throughput and the acuity distribution data revealed a
End Triage Recent financial
bottle neck in the patients leveled as ESI 3 & 4. This discovery,
reports along with discharge and acuity
Y / N metrics
Comments:
provided a clear picture of the distribution of ED visits and most
combined with the department’s recent push to bedside triage
frequent uses/burdens on the system. We combined this readily
for acute patients, suggested to the group that they explore a
available overall data with specific process data through the
split flow model. To further enhance that model, they investigat-
use of a simple data collection sheet. This basic form is custom
ed adding urgent care to the split flow.
Patient in Room
IRMC Emergency Department Data Collection
Date: Patient #:
FUTURE STATE
TIME
Patient Arrives Registration Complete
Begin Triage End Triage
point of service as quickly as possible while ensuring they could
ESI Level? 1
Begin Vitals Vitals Complete
The team sought to speed check-in and move patients to their
Notes: 2
Wheelchair necessary?
4
5 Y / N
capture the appropriate payment. After reviewing the data and criteria for bed assignment, the group discovered that traditional fast track was no longer proving useful.
Vitals completed during registration? Y / N Comments:
Patient in Room
3
By shifting the initial quick registration to a nurse rather than a registrar, it could be combined with a quick sort to one of three care areas. Acute patients moved directly to the treatment area for bedside triage and registration. Similarly, patients suitable
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Who We Are ARRAY-ARCHITECTS.COM
for urgent care moved directly to a small zone to wait and see a provider. Only patients that could not easily be assessed moved to the Rapid Medical Evaluation area. This expanded triage that allows for discharge if appropriate, limits the longer medical
We Are Healthcare Architects
screening to only those patients who need it. The team quickly realized that by using their existing fast track area for rapid medical evaluation and using the existing triage
IRMC ED Arrival
FUTURE STATE MAP 6.11.2014
ED LOBBY-SECOND FLOOR
Outpatient Pavilion entry causes confusion; safety issue
No consistent person/role to call
ED DOOR/ FRONT DOOR/ OPP DOOR
BACKER ACT/ PRISONER/ INJURY
RAPID RESPONSE
AMBULANCE LOW ACTIVITY
Security at ED is a roaming position. Not always at desk
Need to identify space for regist. start
Acute
ED ENTRY Need to add Non-ED Registration After Hours
Bedside Reg. & payment for all patients except urgent care
X Ray Labs
Rapid Medical Evaluation
Quick Registration
Arrival • Patient presents at ED entry • Access to wheelchair
• • • • • •
Pivot RN Name DOB Chief Complaint Phone # Find Existing Patient Record • Visual Assessment
• • • • • • • •
Wait
Roaring? Registrar
RN Assessment Vitals Need List Review Symptoms History Suicide Screen TB Screen Begin Protocols
Sub Wait
Registration
Discharge
Provider More Primary MD to RN Assessment or Reg. at bedside
Registration Urgent Care
• Full Registration • Payment
Discharge
Sub-wait Use Exist Triage as Urgent Care
Lewe
Urgent Care Treatment
Wait in Main Waiting Room
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 decades.
Pargon access to Primary MD ? not open to RNs
• Registration • Mid level Provides Assess • Vitals in Room
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.
• Mid-Level
Develop Registration/ Check out area in Waiting
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.
rooms for the urgent care patients, they could implement their improved process with very little construction. Plans to convert
Array’s Knowledge Communities
the former volunteer desk into a results waiting lounge for the RME patients can be completed if the future process provides the anticipated results. SUMMARIZING CONTINUOUS IMPROVEMENT
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 Thoughts page.
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 organization. We believe the trans-formative improvement that leading health systems, who have embraced Lean and other improvement approaches, have achieved is equally applicable to architecture.
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case study: ED process redesign | PAGE 5
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