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Improving Patient Flow Through the Emergency Department

2012; Lippincott Williams & Wilkins; Volume: 57; Issue: 4 Linguagem: Inglês

10.1097/00115514-201207000-00004

1944-7396

Michelle Johnson,

Healthcare Operations and Scheduling Optimization

Peggy Ames, manager of information systems, and Lee Kauffman, director of managed care and administrative director of laboratory services, both at Winchester Hospital in Massachusetts, contributed to this column and were co-facilitators on one of several Lean Six Sigma projects launched at the Winchester Hospital ED. Improving patient flow in the emergency department (ED) is a strong complement to improving the inpatient discharge process. Patient flow must be viewed as a hospital-wide system in which the issues causing obstacles to smooth flow are identified and eliminated or mitigated. This overall patient flow needs to be broken into components to facilitate parallel improvement projects. In this column, we will focus only on the processes internal to the ED. ED visits increased 38 percent between 1997 and 2007 (Tang et al. 2010). This steady increase in ED patient volume has put a huge strain on hospital facilities and budgets. Adding more staff and spending capital to expand the ED are not viable options for most hospitals, so EDs must improve efficiency and effectiveness through low-cost process improvement efforts. These efforts can provide the hospital with a triple win: Improved patient satisfaction: Less waiting and better service lead to satisfied patients. Improved quality of care: Standard work and improved flow reduces staff stress and minimizes the risk of patients decompensating or having patients leave before they receive treatment. Reduced total cost through higher utilization: More patients can be serviced within the same physical space and without an increase in staff. Exhibit 1 provides a typical emergency department process flow. Providing full details on how to improve all the steps in the ED patient flow exceeds the scope of a column, so we will illustrate key improvement methodologies that, in our experience, are core to process improvement in the ED. EXHIBIT 1 Typical Patient Flow Through an Emergency DepartmentFigure: No Caption available.START WITH “VOICE OF THE CUSTOMER” AND“ VOICE OF THE PROCESS” To gain an initial understanding of the current state of the ED process you must understand how the process is perceived (voice of the customer) and how the process is currently performing (voice of the process). Voice of the Customer By using internal survey tools or external services such as Press Ganey, you can determine the voice of the customer—in this case, both patients' and staff's perceptions. Gathering and analyzing this data will provide valuable insight into how the ED processes are perceived. Using tools such as affinity diagrams and critical-to-quality trees, one can boil down general needs to specific measurable needs by translating statements such as “I want fast and courteous service” to specific requests such as “I want to see a nurse within 15 minutes of arrival” and “I want to be greeted by name.” When we started our ED project at Winchester Hospital, the hospital's Press Ganey scores were in the middle range of the hospital's peer group. We targeted two particular patient-related questions in our project; the before and after results are shown in Exhibit 2. These particular question scores show a dramatic rise, but it is interesting that overall scores on all questions also rose dramatically and overall satisfaction with the ED is now in the top 5 percent compared to peer hospitals. Voice of the Process The voice of the process involves determining how the process is currently performing. This determination can be made through many tools and analytical techniques, a few of which we will examine here. Spaghetti Diagrams Exhibit 1 shows a linear, well-organized path through the ED, but the real patient flow is not always so perfect. For a better view of the real process, look at Exhibit 3. This is a spaghetti diagram tracing the path that one level 3 patient took at Winchester Hospital. (EDs use a priority level index to determine the level of the acuity for each patient. A level 1 patient is the highest priority, as in a life-threatening event, while a level 5 patient is the lowest priority, nonurgent). We traced the patient's ED experience from the time she entered the department until she left to go home. The patient's path through the processes is not always linear; Exhibit 3 shows that the patient went through a series of back-and-forth steps, including many trips back to the waiting room. In this situation, the patient spent only 20 minutes with any clinician, yet her entire journey lasted almost three hours. We also created a spaghetti diagram of nurse movements (not shown) that includes much more “spaghetti,” showing a lot of nurse movement to maneuver patients, look for equipment, find clinical help, and gather supplies. EXHIBIT 2 Press Ganey Scores for Two Patient-Related QuestionsFigure: No Caption available.EXHIBIT 3 Spaghetti Diagram of One Patient's ED JourneyFigure: No Caption available.Baseline Data Analysis At Winchester Hospital, 77 percent of the patients are level 3 and 4 priorities and 21 percent are level 2. Level 2, 3, and 4 patients combined make up 98 percent of the hospital's patient mix, a fairly typical pattern. Level 2 and 3 patients make up 95 percent of inpatient admissions—again, a fairly typical pattern. Having this information provided the team with potential focus areas, helping them see where improvements would provide the largest impact. We gathered information about patient arrival patterns and related staffing levels for the Winchester Hospital ED. The data show that patient volume is highest between 8 am and 8 pm. We found that staffing levels seem appropriate for the arrival flow. However, when analyzing information about departures, we found a significant time lag of departures following arrivals. This indicates that discharges were being batched—the ED was discharging two or three patients in a row instead of discharging patients as they were ready. This issue was confirmed and became an area of focus for our project team. Visuals of the arrival pattern versus staffing levels and admissions and discharges by hour are shown in “57-4 Efficiencies Visuals” on ache.org/pubs/jhmsub.cfm. MAPPING The Winchester team spent time observing the process and gathering information so they could develop a value stream map of the current ED process. In one portion of the process, referred to as door-to-doc (boxes 1 through 5 in Exhibit 1), mapping showed that the patient is pushed through the process. There was no signal to take patients to a room as it became available; instead, an inefficient process of constantly checking about room availability was the norm. Because this often created time delays, it was not unusual to see patients batched and “pushed” into exam rooms. A patient encountered an average 78 minutes in delays plus 27 minutes of processing time for a total 104 minutes from entry to the start of the physician diagnosis. As part of their observation of the current process, the team also conducts a waste walk, identifying wastes in the current process. We identify these wastes using the acronym DOWNTIME (D = Defects, O = Overproduction, W = Waiting, N = Non-Utilized Talent, T = Transport, I = Inventory, M = Motion, E = Excess Processing). In the case of door-to-doc, the Winchester team found more than 20 instances of significant waste. ENGAGE THE TEAM TO IDENTIFY OPPORTUNITIES AND DEVELOP A FUTURE STATE Using the work done in gathering voice of the customer and voice of the process information, the Winchester team explored opportunities for improvement. The team reviewed the wastes in the door-to-doc process and brainstormed potential solutions. Here are some examples: Waste: When a patient arrived they signed a log book, sat down, were called to register, sat down again, and then were called to triage. Potential solution: Bring the patient into triage immediately (if the room is free), eliminating the need for a log book. Registration can be done during the triage process. Waste: There was no standard process to immediately pull a patient to an empty ED room. Instead, the charge nurse was in charge of making this call but often was distracted by other duties. Potential solution: Standardize the work flow; the new practice would be to always fill an empty room unless the charge nurse was reserving the room for incoming ambulance patients. Waste: When a patient entered the exam room, there was a delay in starting the initial nursing workup, which meant delays in getting the doctor into the room. Potential solution: When a new patient arrives, a page is made: “Patient in room 2.” All staff available go to that room to help with the new patient, greatly reducing the workup process time. The team also identified quick wins that could be implemented without much effort or further analysis, some of which are detailed below: Renumber the wall beds to represent the geographical location—the current numbering was confusing to staff and did not follow any pattern. At the start of every shift, have a five-minute huddle to review any process issues, highlight any current bottlenecks, and collect any immediate improvement suggestions. Use the rooms in the Pedi (children) service area during peak morning arrival times—five rooms were reserved for Pedi patients, but that area did not open until noon; the old practice was not to use those rooms, thus contributing to waiting room backlog. After the Winchester team developed their improvement opportunities, they created a future state value stream map. The team targeted aggressive improvement reducing nonvalue time from 78 minutes to 14 minutes and adding 2 minutes more to the process time. The net effect is a 59 percent planned reduction in overall (cycle) time. The current and future value stream maps of the door-to-doc processes are shown in “57-4 Efficiencies Visuals” on ache.org/pubs/jhmsub.cfm. IMPLEMENTING THE FUTURE STATE After creating a conceptual future state, the Winchester team had to address removing the waste. They did this by the developing solutions to the problems just detailed and also by creating supporting work such as the following: Clarifying roles and responsibility for all staff: The team used a RACI (Responsible, Accountable, Consulted, and Informed) diagram to clearly outline stakeholder roles. The RACI diagram lists actions and tasks (e.g., start of shift huddle; triage) and staff roles (e.g., charge nurse, ED tech) and assigns R, A, C, or I to the applicable staff for each step. Creating standard work: A standard work document breaks a step down into tasks, shows who performs the task, lists the task's frequency, and identifies the improvement areas to which the task pertains (e.g., patient satisfaction, safety, efficiency). In creating standard work, ask yourself, “How do I do the work, and why do I do it that way?” Creating visual systems/signals: A real time flow-status dashboard was created that shows the number of patients waiting and whether they have been triaged, the patients' wait times, how many patients were in each treatment area (e.g., Express, Main, Teens), and average time in minutes from greet to triage, room, doctor, and admitting called. Examples of these documents are shown in “57-4 Efficiencies Visuals” on ache.org/pubs/jhmsub.cfm. WHAT GETS MEASURED GETS DONE It is important to establish clear, measurable objectives (targets) with related metrics. It is equally important to understand the concept of balanced metrics that take into account several facets of improvement, such as process time reduction, cost reduction, improvement in quality, and improvement in patient satisfaction. Many organizations struggle with collecting data, but if regular metric updates aren't provided, it is impossible to understand what improvements are working and which need further tweaking. As improvements begin to take effect and metrics move in a positive direction, they become a powerful motivating tool. Everyone likes to know how they are doing. Exhibit 4 lists some of the metrics used to determine project success. It is clear that that the team achieved significant improvements within three months. CONCLUSION Opportunities to improve patient flow in the ED are plentiful, and hospitals that engage staff in an improvement effort can derive substantial cost, quality, and patient satisfaction benefits. Patient comments from a recent Press Ganey survey include the following: “I could not get over the rapid attention and care.” “Best ED visit I ever had at Winchester Hospital; I could not wait for this survey to come in.” EXHIBIT 4 Metrics for Determining Project SuccessTableThe ED staff also gave positive feedback, such as the following: “When this project started, I was very skeptical, but I'm now a believer and I now know that this process works. I would have never believed we could get the results we accomplished.”—A charge nurse “This waiting room used to always be full; now it is usually empty and patients can't believe how efficient we are.”—A patient liaison/greeter Such feedback is a result of what is perhaps the most satisfying result of this project—the incredible sense of pride and teamwork that the ED staff developed.