CLIENT: Orange Regional Medical Center
CASE STUDY
Middletown, NY
Fully understanding the problem allows us to develop solutions that focus on the root cause. Sometimes it is difficult for staff to see what is happening beyond the confines of their reality. In this case, the emergency department (ED) was very crowded with patients waiting for inpatient beds. The ED believed they needed more treatment space, but root cause analysis helped us see that the real need was for inpatient beds.
SERVICE: Transformation
EXECUTIVE SUMMARY
METHOD: Throughput Analysis
Initially focused on redesigning their emergency department (ED), Orange Regional Medical Center (ORMC) engaged Array Advisors to map the current and future state process. It became clear that there were some downstream bottlenecks causing the ED to be overwhelmed with patients.
Challenge The emergency department (ED) is experiencing daily holds. Currently, observation patients are sent to any available bed in the hospital. Staff fears that this bed assignment paradigm may be causing the back-up in the ED. Array looks to provide clarity around the impact of improving flow in the ED and cohorting observation patients.
The ORMC team was interested in seeing if they could increase ED capacity by adding holding beds for admitted patients waiting in the ED for an inpatient bed. We used a simulation model to test the effect of implementing the future state patient flow. Holding beds appeared to alleviate the problem, but we did not believe they were the best use of capital and they clearly did not solve the root cause of the issue. We recommended ORMC perform a study of the inpatient and observation patient interaction to determine if inpatient bed capacity was the root cause.
Solution
We hypothesized that moving observation patients, who were currently being treated
After developing a future state work flow focused on separating the very sick patients from the less sick patients in the emergency department (ED), Array worked to determine how a dedicated observation unit would impact current crowding in the ED.
reduce the number of holds in the ED.
in inpatient beds, to a cohorted unit would create capacity for admitted inpatients and
Array’s modeler developed a second simulation model to study the utilization and bed need of all inpatient units. The model also demonstrated the effect of treating observation patients in a dedicated unit, rather than inpatient units. The models provided the ORMC team with visuals, helping them see the impact of adding an observation unit. This also helped them determine the best use of their capital dollars.
PROJECT HIGHLIGHTS
2
SIMULATION MODELS: 1 ED, 1 INPATIENT
30
OBSERVATION BEDS NEEDED TO REDUCE ED HOLDING
6
RAZ POSITIONS ADDED
Client Profile ORANGE REGIONAL MEDICAL CENTER MIDDLETOWN, NY Recognized by US News and World Reports as a world class regional provider, Orange Regional Medical Center is committed to excellence in all areas. By recruiting top physicians and specialists; by utilizing the most advanced technology and diagnostic equipment; and by never forgetting what the power of compassion in a healing, patientcentered environment means to those they care for. http://www.ormc.org/default.aspx
PROCESS MAPPING We began our study by mapping out the current state of operations in the ORMC emergency department (ED). As the ORMC team developed the current state map, they gained consensus around how patients were flowing through the department, and what some of the biggest barriers to flow were. This allowed them to develop a future state patient flow focused on removing current barriers, leading to a better patient experience. The future state mapping activity resulted in a transformation plan. To attain the metrics specified in this case study, ORMC must completely implement the future state, including each of the items in the transformation plan. We developed a discrete event simulation model to help us better understand whether holding beds would provide enough capacity to reduce the strain from not having an adequate number of inpatient beds currently felt by the ED. EMERGENCY DEPARTMENT SIMULATION STUDY The simulation study revealed that the new process, which shifts the traditional triage activities to a rapid assessment zone (RAZ) and incorporates a pivot nurse, could improve door-to-doctor time seen in the current state, if the appropriate resources are allocated. This initial analysis of ED throughput indicated that admitted patients were being held in the ED for extended durations, leading to the perception that the ED did not have enough treatment positions.
Method THROUGHPUT ANALYSIS The processing rates of each step combine to create total throughput time. Steps with longer durations that occur later in the process create bottlenecks, and non-value-added waiting time will increase the time it takes to get through the system. Array’s experienced team works with you to determine the optimal processsteps configuration that maximizes the value quotient in your system.
The simulation results (Figure 1) helped ORMC staff see how different resource quantities affect average door-to-assessment time and the distribution of door-toassessment times over the patient population. Allowing all ORMC team participants to engage with the interactive results helped everyone on the team understand the impact of changing the available quantities of each resource. Staff expected that most of the ED holds were observation patients, but the data showed us that about 3/4 of ED holds were actually inpatients waiting for beds. To further explore how inpatient bed assignments for observation and admitted patients affects ED throughput, Array developed a simulation model focusing on the interactions between the ED and inpatient unit.
Orange Regional Medical Center • 06.27.2016
1
2
3
4
Main ED Beds
22
22
22
22
RAZ Beds
6
5
6
5
Vertical Beds
10
10
10
10
Holding Beds Door to Assessment (average)
12
12
10
10
5
6.12
6.55
7.85
8.31
0.00
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
12.00%
Percent Waiting Specified Durations for Door to Assessment
10.00% 8.00% 6.00% 4.00% 2.00%
0.77%
1.22% 0.89% 1.34% #N/A
0.00%
0.99% 0.58% 0.87% 0.71%
10-15 mins
15-20 mins
#N/A
0.50% 0.66% 0.62% 0.77%
20-25 mins
#N/A
0.43% 0.53% 0.55% 0.63%
#N/A
25-30 mins
Figure 1: Simulation results decision tool. PAGE 2 | case study: Orange Regional Medical Center
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INPATIENT SIMULATION STUDY The inpatient simulation study helped quantify the impact of adding an observation unit. Most of the ED holds today are admitted patients waiting for beds in an inpatient unit. Currently, the staff treats observation patients in inpatient beds. Grouping the observation patients into one unit will make capacity available in the inpatient units, leading to less crowding in the ED. Given the studies’ results, we recommended adding telemetry monitoring to the two surgical floors (2S and 4W). This will alleviate some of the capacity strain currently experienced on the other floors that have tele-monitoring. Figure 2 shows how much lower the percent utilization is on each of the surgery floors.
Convert to a medical floor with tele
% Utilization
Unit
% Utilization
2S
35%
27%
2S-STELE
66%
45%
3N-CTELE
97%
95%
3E (ICU)
79%
70%
3S-CTELE
85%
72%
3W (ICU)
82%
79%
Convert to tele for cardiac overflow
(no observation unit)
(with observation unit)
3W-M/CTELE
81%
66%
4N
99%
99%
4S
95%
93%
4S-MTELE
96%
95%
55%
41%
78%
72%
5N
97%
97%
5S
91%
89%
5S-MTELE
90%
86%
5W
75%
68%
5W-MTELE
48% No observation unit
24% 25 beds 30 beds 35 beds 69%
58%
We begin all endeavors by considering process before exploring solutions. 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.
CAPITAL SPENDING?
4W
N/A
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.
WHAT CAN WE DO TO OPTIMIZE OUR
4W-STELE
OBSERVATION
Transformation
49%
Figure 2: Results table showing percent utilization with different sized observation units.
Before beginning design on any capital project, it’s important to understand the customer needs, work flow and optimal future state. Our team can guide your organization through pre-design, ensuring clear goal setting, target outcomes, process analysis, process design and decision support. Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.
The addition of an observation unit increases available capacity in the inpatient units, reducing the number of patients and frequency of holding in the ED, allowing Array to remove the ED holding beds from the initial solution. The table in Figure 3 shows the effect on ED door-to-assessment time of adding an observation unit and removing the proposed holding beds. The final future state recommendation for the ED includes removing the 12 proposed
TOOLS USED: Capacity & Utilization Assessment, Consensus, Process Mapping, Data Analysis, Data Visualization, Simulation Modeling
holding beds and adding four additional Main ED beds to keep the average door to assessment time at the goal of about six minutes. We also recommend adding an observation unit to increase inpatient bed capacity. Future State (from ED study)
Future State With OBV Unit
Future State With OBV + Increase Main ED Beds (as drawn)
Main ED Beds RAZ Beds Vertical Beds Holding Beds
22 6 10 12
22 6 10 0
26 6 10 0
Average Door to Assessment Time (min)
6.12 minutes
10.04 minutes
6.70 minutes
Observation Beds
0
30
30
Figure 3: Results table showing how ED door to assessment time is affected by the addition of 30 observation beds.
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case study: Orange Regional Medical Center | 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.
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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: APRIL 2017