CLIENT:
Children’s National Medical Center CASE STUDY
Washington, DC
Modeling patient arrivals can ensure appropriate resource utilization and maximize patient flow. 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.
CHALLENGE
EXECUTIVE SUMMARY
An urban academic medical center
Before facilities consider architectural solutions, we help them design the process. In
focused on pediatrics sees more
this case, lean improvement work had been underway in the emergency department.
than 85,000 visits each year in their
The group reached a threshold they believed needed to be overcome using an
emergency department. Designed 15
integrated process and space configuration solution.
years ago, the segregated pods and small triage area limit flexibility and result in long lines and unsafe conditions.
When appropriate, we employ simulation modeling and predictive analytics to help clients make important early-design decisions with clarity and certainty. Rapid testing and data-driven decisions guide our work. We were able to leverage existing throughput data to rapidly build a simulation model. The model incorporated existing patient census data, which was quickly enhanced by
SOLUTION
the expertise of the nurses and doctors in the room. As we built the simulation model,
Resource Utilization
output was matching reality.
Through process mapping and discrete event simulation, a multidisciplinary team was able to test alternate patient flow approaches to identify the optimal balance of process time and staffing resources to ensure consistent success.
PROJECT HIGHLIGHTS
we continued a dialogue with the emergency department staff to ensure that the Using the simulation model, our cross-functional team of engineers, nurses, doctors and other support staff was able to test a number of different patient flow options. As we experimented with different solutions, everyone in the room could see the impact of adding an additional security desk staff or removing a triage room. This hands-on approach helped the group quickly arrive at the optimal solution, which balanced patient waiting times and staff utilization, and ensured each provider was working at the top of their licensure.
<5min Expected Average Wait for Triage
3
Security Spaces Needed
5
Triage Spaces Needed
CLIENT PROFILE Children’s National Medical Center Washington, DC
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.
As the only health system designed for
The care of emergent pediatric patients is complex. Rapid decompression and
kids in the Washington, DC, metropolitan
non-specific symptoms make any unsupervised wait dangerous. In an effort to gain
area, CNMC believes every child should
as much information as possible, a two-step triage and assessment process was
be cared for by professionals who
in place. Protocols could be started early and providers knew that patients were
have devoted their career to children’s
evaluated in detail, even if they had a long wait. The unintended consequence was a
medicine. At Children’s National Health
bottleneck at assessment.
System, they are dedicated to providing the best pediatric care for their patients, families and community. They are the premier provider of pediatric care in the region and the only freestanding children’s hospital between Philadelphia and Atlanta. Serving the nation’s children for more than 140 years, Children’s National is a proven leader in the development and application of innovative new treatments for childhood
To combat the problem, the providers felt a redesign of the arrival area, in conjunction with combining some existing care steps to reduce patient moves, was necessary. 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.
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
illness and injury.
Acute Treatment
childrensnational.org 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
TOOL
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
Resource Utilization A resource is anything that aids the movement of work through a system. Organizations hope to optimize their resources’ utilization because they typically have an associated cost, which decreases with higher utilization. After determining ways to maximize throughput and implement flow, we can ensure full resource utilization without creating nonvalue-adding process steps.
Figure 1: Current state process map including average process time and time between steps, as provided by internal improvement group.
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 require a high number of triage nurses to handle peak volumes. The providers felt it wasn’t the best use of so many highly-trained pediatric emergency nurses to be tied up in triage.
Page 2 | Case Study
Focusing then on reducing overall length of stay (while still attempting to reduce patient moves), the group instead moved assessment to the bedside and reduced
TRANSFORMATION
the initial contact to reflect a more conventional triage. This allowed them to
Our core mission is the same as that
quickly register and evaluate the large volume of patients they see each day with
of our clients: improve the quality of
wait times of less than five minutes for 99.02% for all patients.
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 team members to be agents for good change. We begin all endeavors by considering process before exploring solutions are explored. Our team can guide your organization through pre-design, ensuring clear goal-setting; target outcomes; process analysis and design; and decision support.
Figure 2: Future state process map shows continuous forward progress and simplified check in/triage process.
Future state
Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.
nursing assessment to the bedside, patient throughput could improve by focusing
How can we ensure effective resource utilization?
on the key information at each step. Through simulation, we determined that
Every aspect of the healthcare industry
By redesigning the process of security, registration and check-in, and shifting the
adding one additional registrar reduced overall wait times and allowed two nurses to return to bedside care within the current staffing model.
relies on resources, including staff, equipment and space. It’s imperative
Shifting to a more traditional triage approach left some providers concerned about
that organizations utilize their resources
waiting room oversight. Through continued process-led design, we developed
effectively. Our qualified consulting
a one-way flow model that moves patients to sorted waiting areas that can be
team can help your organization develop
overseen by clinical staff immediately following initial triage. This arrangement
a strategy for utilization optimization,
also allows the triage nurses to maintain visual oversight of the main entry.
ensuring that every resource is providing
No process is perfect. This configuration leaves room for some real-time, key process shifts pending census. Registration leadership can support front desk staff through their direct location. Additionally, nursing leadership can implement
the most value while improving process flow.
Tools used:
a pivot nurse pre-sort process if volume spikes unexpectedly. The front desk and
Process Mapping, Observation, Simulation
triage area was expressly designed to support a flexible staffing model that can
Modeling, Adjacency Diagrams
evolve over time.
Figure 3: Simulation model (right) showing simplified adjacency configuration (left) with three security/check-in staff and five triage bays. Cast Study | Page 3
DISCOVERING YOUR HEALTHCARE SOLUTIONS TOGETHER We are innovators who specialize in the areas your system seeks out to leverage its valuable operational and facility resources. Array Advisors has the expertise and skills to reach beyond your milestones and provide you the decision support you need.
OUR SOLUTIONS
OUR SERVICES
We are dedicated to improvement.
How can we assist you?
Problem-solving and forward-thinking
We are Array Advisors, your trusted partners in Strategy Development, Organizational
individuals lead our efforts, which focus on your unique place in the healthcare delivery spectrum. Our knowledgeable staff can help you solve strategic business problems and develop a method to improve efficiency and utilization.
Transformation, and Facility Informatics. The challenges you face are not unique, but your solutions should be. Through a partnership of Strategy and Transformation we help you achieve and sustain. Our process begins by understanding your current operations and clearly defining your system’s goals before generating options. We employ a variety of integrated methods tailored to your strategic challenges, such as process mapping; operational planning; and healthcare real estate portfolio optimization, to help position your organization for future success.
MEET YOUR ADVISORS
Informatics Building Information Model management (BIM) is an enabler of most other technology trends in the Architecture, Engineering, Construction, Operations (AECO) industry, including but not limited to: sustainable design, offsite fabrication, LEAN construction, and energy efficient operations. Carefully considering how best to leverage virtual/digital representations of physical buildings can provide significant returns on innovation throughout the entire lifecycle of your facilities.
Strategy The need for healthcare real estate portfolio optimization has never been greater. With the acceleration in mergers and acquisitions, as well as the evolution of clinical models, healthcare organizations must continuously evaluate their physical assets and maximize the value they derive from them.
Transformation Transformation and lean methods are very useful when focusing on operational process improvement. By bringing all constituents together and giving them the tools to experiment and test new ideas, current state barriers can be identified and transcended.
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Published: NOVEMBER 2015