CES Current State and Opportunities for Improvement Final Report April 18 2017 IOE 481 Team 2 Gagan Gupta Anavir Shermon Emily Smith Hailey Willett Childrens Emergency Services Process Overall Goal of CES ID: 763073
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CES Current State and Opportunities for ImprovementFinal ReportApril 18, 2017IOE 481 Team 2Gagan Gupta, Anavir Shermon, Emily Smith, Hailey Willett Children’s Emergency Services
ProcessOverall Goal of CESFocus on quality care of patient while maintaining patient safetyArrivalAssessment Treatment Disposition Planned/Unplanned Arrival Safe/Unsafe ID Band/Severity Level Triage Nurse Primary Nurse Resident/Attending Physician Order diagnostic tests Treatment by physician/nurses Treatment by consultant Discharged Admitted for observation or inpatient care Other (transfer to OR, expire, etc.)
Key IssuesDiversion from procedures due to required impromptu decision making & frequent distractions Nurses and physicians are often overwhelmed due to variability in arrival patterns Requirement to bypass standard process when high acuity patient arrives causes chaos. Unable to gauge acuity of patients due to inability to communicate Nurses spend longer than necessary getting patient background
Goals & Objectives321 4 6 5 Reduce NVA time from process steps Develop detailed Value Stream Map Improve CES Operations by focusing on Patient Safety and Quality of Care Eliminate bottlenecks in process flow Reduce cognitive load on staff Increase patient throughput Identify opportunities for improvement
MethodsGemba Walks Time Studies Nurse and Provider Survey Data Analysis Literature Review
Interruptions DocumentationGemba WalksInefficiencies Some triage nurses document in the room during triage, while some document after outside in the central staffing area Charting can still be happening 2-3 hours after the patient leaves Attending physicians often get interrupted by phone calls or questions Consult calls can hold up process Attending's must handle and approve all transfers Portable weight scales located far away Residents/PAs can administer full treatment depending on condition, but still need to be checked/signed off by attending Attending physician handoffs take significantly longer than primary care nurse handoffs between shifts
Front Desk Observation Spreadsheet
Data Collection Log
Qualtrics Survey
Findings & ConclusionsFigure 1: Front Desk Process & Wait TimesSample Size: 106, Source: IOE 481 Team, Collection Period: February-March 2017
Findings & ConclusionsFigure 2: Percentage of Triage & Primary RN Eval that occur Individually or Simultaneously Total Process Time when evaluated individually: 22 min Key Insight Total Process Time is 37.8% shorter when Triage and Primary RN Eval occur simultaneously Total Process Time when evaluated simultaneously : 15 min
Findings & ConclusionsFigure 3: Nurse and Provider Process TimesSample Size: 75, Source: IOE 481 Team, Collection Period: February-March 2017
Excel Data Summary Sheet
Excel Data Summary Sheet
Excel Data Summary Sheet
Final Value Stream Map88 min
Final Value Stream Map (Part 1)
Final Value Stream Map (Part 2)88 min
Application of Lean in the ED(Dickson et al., 2009)Redesigning ED patient flows (Flinders) (King et al., 2006 in Australia)Literature Review1 2 Action Creation of patient “streams” for patients predicted at triage to be admitted or discharged (or fast tracked) Functional team of nurses and doctors dedicated to each stream Result Mean LOS for dischargeable patients reduced from 3.7 to 3.4 hours, and admitted from 8.5 to 7.0 hours (statistically significant) Action Improved signage for directing patients. Laboratory tests/X-ray studies ordering and sending done earlier in the process Nurse, resident, and attending get the patient’s history simultaneously, reducing duplication of history and saving staff time Result Triage WT decreased from 3.18 to 2.63 mins Evaluati on WT decreased from 13.68 mins to 11.65 mins
RecommendationsEffortImpact StarsQuick Wins Low Hanging Fruit Thankless Initiatives Stream System Automation of Registration Process Standardization of Process Steps Addition of Signage Potential re-purposing of café entrance desk On-the-go digital documentation Simultaneous Evaluation Figure 5: Impact-Effort Matrix
Standardization of Process StepsFront Desk TriageLab & ImagingAdmittance
Stream SystemScreener Nurse predicts whether patient will be admitted or dischargedAssigned nurses, attendings, and residents focus on quick turnover of dischargeable patientsFrees resources, staff, and space for high acuity patients, and will reduce overall LOS for all patients High Acuity Stream Low Acuity Stream (Fast Track) Shared resources, staff, and rooms as needed
StarsOnline app and/or multiple automated stations for transfer patients, referral patients, and low acuity patients to check-in rather than wait in queueConcurrent diagnosis of patient by nurse, resident, and attending to minimize repeated gathering/transfer of medical history
Future DirectionsDisposition & DischargeDiagnosis & TreatmentMeasurement of Wait Time
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