CASE STUDY
CLIENT: Mid-Atlantic Regional Community Emergency Department
Testing variations of a newly designed process before implementation uncovers potential inefficiencies. Among the critical factors identified for rapid study was the need to right-size the building program to avoid constructing superfluous square footage. An optimized program was achieved by developing a patient flow that incorporates universal resources that could flex as demand fluctuates during the day.
SERVICE: Transformation
EXECUTIVE SUMMARY
METHOD: Process Design
When given the opportunity to design a greenfield hospital, our client knew they wanted to do it correctly. Their desire to improve applied to the physical space and the processes performed within. Using process analysis and design, we engaged a crossfunctional team from the emergency department (ED) as they explored the impact of
Challenge
multiple solutions.
Explore different process designs to minimize the emergency department’s waiting time and incorrect resource utilization. Determine potential benefits of universal resources.
We began by observing current ED operations, exposing us to the process and revealing potential areas for improvement. Using process analysis, we worked with the team to map the current process. This mapping exercise allowed the team to see where reality deviated from expectations, and how their traditional triage model impacted patient waiting times.
Solution
As the clinical team developed their desired future state, they began to realize how
Using 15 months of patient data, Array built multiple variations of a discrete event simulation model to show resource utilization and waiting times for different patient types. The simulation results helped emergency department physicians, who were concerned with the ability to offer a specialized pediatric experience, see the benefits of operating under a universal model.
PROJECT HIGHLIGHTS
8
different variables could affect waiting times for varied patient types. Many questions surfaced, including the effects of providing dedicated pediatric care. Our Healthcare Systems Engineer developed a simulation model to test the impact of each potential patient flow and demonstrate the effect of varying resource allocation strategies. Ultimately, the team chose a hybrid model that combined a specialized pediatric experience with universal flex beds. The new process includes quick triage to help minimize patient waiting and improve the delivery of care.
PATIENT FLOW VARIATIONS TESTED
15
mths
PATIENT DATA DRIVING SIMULATION MODEL
18
%
PATIENTS ARRIVE 9A-12P
CURRENT STATE
Method
A cross-functional team gathered to discuss the way patients currently flow through the ED. The outcome of this exercise is a current state map, which depicts
PROCESS DESIGN Most times, process design follows process analysis. In cases where a process does not already exist, its design can come first. After analyzing the process, we use process design to determine how the results can be transformed into a new way of working. When planning how a new process will work, it is important to keep in mind the successes and failures of the current system discovered in process analysis. Our skilled facilitators can lead you throughout the process transformation, from analysis to design.
the different flows discussed. Often in these meetings, staff will uncover some discrepancies between how patients are expected to flow through the system and how they actually flow. The current state mapping session provides value through its focused discussion and consensus-based decision making. The discussions resulting from this mapping session led the team to realize how the triage process impacted patient waiting times. Current State Map
FUTURE STATE
Emergency Department August 26th, 2015
GENERAL IHN WOODBURY ED IS PART OF TEAM HEALTH
57,000 VISITS/YEAR +/- 7,000 PSYCH
MONITOR TECH FOR HOUS ON TELE UNIT
5 PERCENT OF VOLUME ARRIVE @ 9AM
BED TO NURSE – 2 MINUTES BED TO DOCTOR – 9 MINUTES
TELE TRACKING OF BEDS WILL BE ONLINE SEPTEMBER 27. 2015
DOOR TO DISPOSITION220 MINUTES DOOR TO DISCHARGE240 MINUTES
18% ADMITTED FROM E.D.(ROUGHLY 85% OF HOSPITAL ADMISSIONS)
After discussing some current state
DOOR TO TRIAGE6 MINUTES DOOR TO BED30 MINUTES DOOR TO NURSE – 32 MINUTES DOOR TO DOCTOR39 MINUTES
ESI BY % (W/O PSYCH) •ESI 1 – 5% •ESI 2 – 10% •ESI 3 – 50% •ESI 4 – 20% •ESI 5 – 20%
CONSENT TO TREAT MAY NOT BE SIGNED PRIOR TO
INVESTIGATE NURSE SCRIBES
INVESTIGATE DOCTOR TO ORDER TIMES
WHAT PERCENT OF DRAWS NEED TO BE REDRAWN?
RESAEARCH SCRIBE WORKFLOWS & RESPONSIBILITIES AT OTHER FACILITIES
PROVIDE DATA ON ARRIVALS BY ACUITY & TIME & LENGTH OF STAY FOR WHOLE YEAR
ARRAY TO SEND SPLIT FLOW CASE STUDIES TO IHN
BEDSIDE REGISTRATION
BEDSIDE CHARTING NOT AVAILABLE IN ALL ROOMS
TREATMENT
ULTRASOUND TRANSPORT COMMUNICATION VIA PHONE – NO RECORD
process pain points, the team designed
CHARGE NURSE DOING TRIAGE/BED ASSESSMENT IN HALL FOR AMBULANCE PATIENTS LONG WAITS – ONLY (1) REGISTRAR
PATIENT ARRIVES AT CHECK-IN
a future state to help alleviate some
•NAME •DOB •ARM BAND •AUTO-POPULATES IBEX
PATIENT ASSESSMENT
TRIAGE NURSE TAKES PATIENT TO MAIN E.D. TREATMENT
•RN •MD – SOMETIMES •TECH - SOMETIMES
PHYSICIAN WRAP UP •PHYSICIAN TALKS WITH PATIENT •DISCHARGE ORDERS ARE ENTERED •PAPERWORK IS PRINTED AND GIVEN TO NURSE
STANDARDIZED CART BASED SUPPLY SYSTEM
•DEDICATED CT •(2) DEDICATED RAD ROOMS •MOSTLY IV CONTRAST
RETURN TO WAITING ROOM
of their obstacles. A future state map
UNABLE TO PERFORM STANDARD PROTOCOLS IN TRIAGE
NO DIRECT COMMUNICATION/ TRACKING TO INDICATE NEED FOR REDRAW
DELAYS FOR PATIENTS NEEDING ULTRASOUND – NOT IN DEPARTMENT
6-BEDS RN&TECH – 10AM-1AM MD – 10AM-10PM PA -2PM-1AM
SEE TRIAGE NURSE •INITIAL ESI •HEIGHT •WEIGHT •ALLERGIES •VITALS •CHIEF COMPLAINT •EKG
PATIENT DISCHARGED
DISCHARGE PROCESS NOT AUTOMATED
REGISTRATION COLLECTS CO-PAY AT BEDSIDE
TESTS/IMAGING
TRIAGE NURSE IS TRANSPORTING PATIENT
NO CLINICAL EVALUATION AT CHECK-IN
PATIENTS GET LOST FINDING CHECK-OUT
NURSE REVIEWS DISCHARGE WITH PATIENT •PERSCRIPTIONS •DISCHARGE INSTRUCTIONS
HEMALIZED SPECIMENS REJECTED – CAUSE REWORK
QUICK T •VITALS •CHIEF COMPLAINT •40% OF TIME
PATIENT GETS ADMITTED NURSE NOT AVAILABLE WHEN PATIENT READY TO DISCHARGE
MEDICAL
EQUIPMENT DOES NOT POPULATE EMR
PATIENT TREATMENT
BED ASSIGNMENT ONLY OCCURS WITH PHONE CALL
IF HIGH VOLUME NECESSITATES
ARRAY Jonathan Bykowski Noah Tolson James Britt Carolyn Lee Pat Malick Ryan Keszczyk Diana Louden
PATIENT STILL USING ED RESOURCES AFTER ADMISSION PRIOR TO TRANSPORT
AMBULANCE
WALK-IN
INSPIRA Tracy Shaw June Long Dr. Jim Bonner
NO RECORD THAT THERE ARE ISSUES WITH LABS – LONG DELAYS
TRIAGE NURSE TAKES PATIENT TO FAST TRACK BED
HEMOLIZED SAMPLES CAUSE SIGNIFICANT DEALYS
ONLY (1) TRIAGE NURSE IBEX DOES NOT AUTO-POPULATE SOARIAN CLINICALS
was created on a large sheet of paper
MOST BEHAVIORAL HEALTH PATIENTS – ESI 2
TRIAGE NURSE TAKES PATIENT TO BEHAVIORAL HEALTH
SEEN BY MENTAL HEALTH NURSE, TECH, & SOCIAL WORKER
PROVIDER SCREENING
24 HOURS TO MAKE DISPOSITION FOR BEHAVIORAL HEALTH
DEDICATED SECLUDED BEHAVIORAL HEALTH INCREASED OUTCOMES & DECREASED ISSUES
using sticky notes and markers. This format allows them to see the entire process at once and can easily be changed as the team makes decisions. As in the current state mapping session, we use consensus-based decision-making to ensure that all voices are heard and the entire team agrees on the final decision. In this future state, the team decided to use a split flow model to alleviate patient waiting times. We believe that if those who do the work design the new process, it will lead to improved frontline support of the new way of working. Future State Map
THERE WILL BE AN AMBULANCE QUICK LOOK SPACE
SPACE FOR EMS
AMBULANCE
SYMBOL KEY
PARKING LOT
QUICK REG/LOOK
PATIENT ARRIVES
• REGISTRATION BASICS: NAME, DOB, CHIEF COMPLAINT • PIVOT RN QUICK LOOK
TOUR VIRTUA VORHEES & ST. MARY LANGHORNE
REQUEST FOR 6 BED B.H. POD AT NEW FACILITY
NEED TO INVESTIGATE DEDICATED PEDIATRIC ZONE WITHIN THE E.D.
RESEARCH OPTIONS FOR DISCREET METAL DETECTION/SECURITY
EXPLORE SIMULATION MODEL OF STAFF IN E.D. INTAKE: RN/ M.D./ PHARM. TECH
WILL THERE BE A DEDICATED INPATIENT PEDIATRIC UNIT?
THERE WILL BE FAMILY SPACE NEAR THE CRITICAL CARE AREA
PATIENT TO MAIN E.D.
THERE WILL BE NON-VERBAL CUES REGARDING PATIENT LOCATION
AUTOMATED WORK QUEUE SYSTEM
PATIENT TO BEHAVIORAL HEALTH
WALK-IN
ABILITY TO REGISTER AND DOCUMENT IN A SEAMLESS PLATFORM IMMEDIATELY
PATIENT REGISTRATION HAPPENS BEDSIDE
• GREETING • REGISTRATION BASICS: NAME, DOB, CHIEF COMPLAINT • PIVOT RN QUICK LOOK • DOCUMENTER PRESENT
THERE WILL BE A TEAM WITH A PIVOT NURSE AND A DOCUMENTER
PATIENT TO INTAKE -JOINT VISIT W/ PROVIDER, RN, & PHARMACY TECH -VITALS -HISTORY -ALLERGIES -WEIGHT -HEIGHT (MAYBE) -LABS -EKG -REVIEW MED RECORD W/ PHARMACY
PATIENT LEAVES E.D. WITHIN 60 MINUTES OF ADMISSION DISPO
OBSERVATION PATIENTS ARE MANAGED BY DEDICATED STAFF
ACCESS TO PNEUMATIC TUBE SYSTEM THAT CONNECTS WHOLE HOSPITAL
QUICK REG/LOOK
PATIENT ARRIVES
NON-EMERGENCY OB PATIENT SHOULD NOT BE PROCESSED THROUGH E.D.
TRANSFORMATION CLOUDS
ADMISSION/ OBSERVATION
DESK SPACE FOR ENOUGH QUICK LOOK TEAMS BASED ON ANALYTICS
ARRAY Jonathan Bykowski Noah Tolson James Britt Carolyn Lee Ryan Keszczyk
INSPIRA Tina McCormick Tracy Shaw Dr. Jim Bonner
EXPERIENCE CLOUDS
INPATIENTS WILL NOT BE TAKEN TO E.D. FOR IMAGING
PIVOT NURSE AT AMBULANCE & WALK-IN ENTRANCES
SENSE OF SECURE ENVIRONMENT FOR PATIENTS AND STAFF
Emergency Department September 18th, 2015
THERE WILL BE DEDICATED CT, RAD, & U/S IN E.D.
PATIENT TO IMAGING
• ESI 1 • ESI 2 • ESI HORIZONTAL 3
PROCESS STEPS
THERE WILL BE CLINICAL OVERSIGHT IN THIS SPACE
OPPORTUNITY FOR PRIVATE CONVERSATION
PATIENT TO PATIENT LOUNGE • STAFF COLLECTS VITAL SIGNS (ON-GOING)
THERE SHOULD NOT BE A LINE
GOODBYE HUG
CHECK OUT
• STAFF COLLECTS VITALS • M.D. SEES PATIENT & GIVES DISCHARGE INSTRUCTIONS
• SIGN DISCHARGE PAPERS • CO-PAY
DISCHARGE
VARIETY OF SEATING TYPE
PATIENT TO LOBBY TREATMENT •SAME ROOM AS INTAKE
E.D. LOBBY
GOODBYE HUG • M.D. SEES PATIENT & GIVES DISCHARGE INSTRUCTIONS
COMPLETE NURSING • REMOVE I.V. • VITALS
EMERGENCY DEPARTMENT
Figure 1: Current state map showing patient flow through the ED (top right). Figure 2: Future state map showing ideal patient flow through the ED (above). DATA ANALYSIS After the team developed their future state patient flow, they were interested in seeing how the new process would work. The architects who were designing the new space also wanted to determine, with a high level of confidence, what the optimal allocation of space types would be using this new patient flow. The client provided 15 months of patient data, which we analyzed for trends and tested for accuracy. The patient arrival distribution for adult and pediatric patients was normalized to determine if there were any differences in the arrival time of these two patient populations. This can be seen in Figure 3.
PAGE 2 | case study
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SCENARIO DEVELOPMENT AND SIMULATION
Transformation
Once we analyzed the data and made some high-level, we built a simulation model that represented the current system. We applied the client’s data to this model to test it for accuracy. After ensuring the model was running just like the actual system, we made changes to reflect the new, ideal way of operating. A simulation model allowed us to test various scenarios represented by the new patient flow. In this split flow model, patients are triaged as soon as they arrive, and directed to the appropriate care. The first two areas a patient might encounter are the Main ED or intake. After intake, a patient could be directed to the Main ED, vertical treatment, or a results waiting area. The physicians were very concerned about how pediatric patients would be treated in this new patient flow, so we used the simulation model to test different scenarios. We created and tested eight different patient flows to determine the
Patient Arrival Distribution 9%
optimal number of resources
8%
and direction of patients.
7%
FREQUENCY
6%
Each option was summarized
5%
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 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. Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.
in a single page that shows
4%
3%
the flow, expected waiting
2%
1%
0% 12:00:00 1:00:00 2:00:00 3:00:00 4:00:00 5:00:00 6:00:00 7:00:00 8:00:00 9:00:00 10:00:00 11:00:00 12:00:00 1:00:00 2:00:00 3:00:00 4:00:00 5:00:00 6:00:00 7:00:00 8:00:00 9:00:00 10:00:00 11:00:00 AM AM AM AM AM AM AM AM AM AM AM AM PM PM PM PM PM PM PM PM PM PM PM PM BIN Pediatrics
Model 2-2 |
times, and specific resource
HOW CAN WE IMPROVE FLOW?
utilization.
There are many tools available to see how work flows through a system. Value stream mapping is a strategic exercise that can be used to look at the flow of work from customer request to fulfillment. Process mapping focuses on detailed work flow elements and can be used to identify non-value-adding steps that reduce efficiency and add to lead time.
Adults
Peds Beds Available as Resource for Horizontal Patients Peds Directly to Peds Beds (Peds Under 13)
Behavioral
Area=F
Area=F
Lounge
Main ED
Quick Reg/Look
ESI 1,2 Peds ESI 1
Vertical
Age<13 ESI 1,2 Peds ESI 1
Peds
Intake
Age<13
Vertical
Resource
Count
Intake
10
Behavioral Bed
6
Main ED Bed
14
Peds
6
Vertical Trmt
12
Vertical
Intake
Resources Available
Horizontal
Peds
*Overflow
TOOLS USED:
Main ED
Lobby (wait)
A3 Dashboard, Observation, Adjacency Diagram, Systems Approach, Collaboration
Horizontal
Census
Waiting for Resource
Overflow Use
Incorrect Resource Use
Patient Type
Count
Behavioral
3,067
ESI 1, ESI 2
13,276
ESI 3, ESI 4, ESI 5
42,017
Resource
Patient Type
Count
Patient Type
Count
Resource
Patient Type
Count
Time (min)
Horizontal ESI 3
Main ED
Behavioral
167
Behavioral
25
ED
Horizontal ESI 3
185
Ave: 10; Max: 54
Vertical ESI 3, ESI 4
Intake
ESI 3, 4 Vert
1,007
Main ED
371
Intake
ESI 3, 4, 5
1,463
Ave: 12; Max: 105
Main ED
Peds
460
Peds
282
Vertical
Lounge ESI 4, 5
1,033
Ave: 10; Max: 108
Peds
8,385
Peds
Main ED
852
Total
677
Peds
Horizontal ESI 3
96
Ave: 10; Max: 49
Total
66,745
Lounge ESI 4, ESI 5
10,501 26,221 5,295
Figure 3: Patient arrival distribution (top left), results from one simulation model scenario (above). OUTCOME The simulation model provided powerful information that gave the physicians confidence in their decisions. By demonstrating the potential impact that each resource had on the system, the simulation model also helped the architect decide exactly how many rooms to build in each zone, without fear of building too much or too little space. This led to a right-sized emergency department that is able to support the current and future volumes.
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case study | PAGE 3
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