Case Study: Improving the ED Patient’s Experience

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.

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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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