Improving the ED Patient’s Experience

Case Study: Improving the ED Patient’s Experience

A Deeper LookIn communities with limited choices, emergency departments serve many roles. Understanding the unique needs of a facility and its population are critical to developing the best solution. One size no longer fits all. We employ Lean Assessment and Design strategies to help each client focus their resources to achieve the most improvement.

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PROCESS OVERVIEW

Our Rapid Lean Design Events are geared to help clients quickly assess their current con-dition, map out patient flows impacted by the process, identify areas for improvement or streamlining, and then establish an ideal future work flow. This future work flow is the critical first step in creating a viable and sustainable project.

The RLDE is a swift and targeted multidisciplinary workshop often consisting of two or three sessions. When appropriate, data is collected between sessions to better focus improve-ment activities.

Implementation Methods:

• Observation & Current State Mapping

• Data Collection

• Future State Mapping

• Develop the Road Map to Implementation

CHALLENGE

A fractured check in and triage process that evolved over time left patients waiting in long queues, sharing private information in the open lobby. Safety and length of stay concerns prompted Array to suggest a complete throughput analysis before de-veloping front door renovation solutions.

SOLUTION

After careful data collection and process analysis an improved future state process was developed and imple-mented with only minor space reconfigurations. The facility was able to test the process in their current department to be sure it would drive improve-ment before expending capitol dollars.

Modernize and Upgrade

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CURRENT CONDITIONS

A community hospital serving a large indigent population sees over 57,000 visits a year. While their facility was expanded and redesigned in 2004, the physical space and its care model were no longer serving the needs of the community. Attempts to speed care time led to additional clinical steps at check-in that created difficult privacy situations. Silos between registration and clinical providers (software and staff) compounded the gaps and duplication in information gathering.

While the ED used a traditional fast-track model, all patients were screened identi-cally through traditional triage. Efforts to shorten stays for low acuity patients were well-aimed, but the non-standard work caused unpredictable delays at triage as well as patient dissatisfaction.

Facing the same economic pressures as all emergency departments, the hospital wanted to offer urgent care style services within the ED and improve their ability to funnel patients to the most appropriate provider, while capturing payment at the appropriate time.

Through the analysis of current state data and a careful review of emerging care models in other facilities, we worked with a multidisciplinary stake holder group that included providers, administrators, volunteers, and supporting services to develop an improve future state that could leverage the existing architecture.

We were able to redesign their process without redesigning their space.

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CURRENT STATE

After observing the process in action, we worked with a multi-disciplinary team including nurses, patient care techs, regis-tration clerks, physicians, and department leaders, to map the current state process and identify opportunities for improve-ment.

DATA

A variety of data sources were used to analyze the current state. Recent financial reports along with discharge and acuity metrics provided a clear picture of the distribution of ED visits and most frequent uses/burdens on the system. We combined this readily available overall data with specific process data

through the use of a simple data collection sheet. This basic form is custom created for each client and tailored to their specific current state process flow.

For one week staff tracked the overall process steps as a representative sample of patients moved through the system. This information was then overlaid on the current state process map to complete the picture of the existing system and its pain points.

Both the throughput and the acuity distribution data revealed a bottle neck in the patients leveled as ESI 3 & 4. This discovery, combined with the department’s recent push to bedside triage for acute patients, suggested to the group that they explore a split flow model. To further enhance that model, they investi-gated adding urgent care to the split flow.

FUTURE STATE

The team sought to speed check-in and move patients to their point of service as quickly as possible while ensuring they could capture the appropriate payment. After reviewing the data and criteria for bed assignment, the group discovered that traditional fast track was no longer proving useful.

By shifting the initial quick registration to a nurse rather than a registrar, it could be combined with a quick sort to one of three

Implementation

Arrival

• Patient presents at ED entry

• If needed, staff brings a wheelchair to car

Emergent Distress

• Immediate Triage Assessment

• Registration comes to Triage Room or get info from family

Triage RN Calls

Charge RN• Call to assign patients to rooms for bed side triage if rooms are open

Chart to Triage

• Medic places chart in plastic bin or gives to RN

Room

• Bedside Triage if room open

Registration

Booth

Triage

(+- 2-3 min)• Vitals if not complete

• Review chief complaint

• Review Symptoms• History• Med rec if volume low

• Suicide screen• TB screen• Begin protocol if no room available

• Call charge RN to assign room

• Labs only if protocol started

• Sometimes to Xray/ orders if in protocol

Wait

Wait

Wait

Discharge

Quick

Registration• Name• DOB• Scan Photo ID• Chief Complaint• Do they have an MD? (ALL ON CLIPBOARD)

Return Clipboard• Patient gives clipboard to registrar

• Registrar creates an account and checks existing acct. +/- 2 min

• Ask have you been a patient before

• Ask for SSN if can’t find record (not often)

• Print labels• Arm band patient• Paperclip check in form and labels and give to Medic

EKG

• Chest pain patients

• Medic does EKG• EKG walked to MD for review

Lab/ Xray/ Mid-Level

Holding• Triage 3 as a holding room

• Used as sub wait

Mid-Level

• Eval patient• Treatment• Order Meds/Tests

Minor Care

• Dedicated mid-level staff & RNs

Vitals if Medic

• Sometime during quick registration

• BP, Pulse, Respiration, Weight/Height (ask only)

• Ask chief complaint• Visual Assessment

Medic not always at front desk

Verbalizing chief complaint has privacy issues

Mass of patients crowd

desk with clipboards

Length of quick registration can

delay Triage documentation

MInor care also now sees patient

that are level 2 and going to main ED

Concern over to discontinuation

of badging

Staff notes that not having a

constant security presence is a

danger

Bedside Reg does not

always occur before visit

ends

No minor care

waiting

No PC in rooms

Might delay flow

Privacy Issue

Charge RN has no visual oversight of Minor Care Room

Status, but responsible for Room Assignments

New requirement to list admitting Dr. at time of

registrastion causes longer accounts creation

and its corrected later

No security monitor in

Triage

Outpatient Pavilion entry causes

confusion; safety issue

No consistent person/role to

call

ED DOOR/ FRONT DOOR/ OPP DOOR

RAPID RESPONSE

BACKER ACT/ PRISONER/ INJURY

AMBULANCE LOW ACTIVITY

CURRENT CCTV CAMERA VIEWS

DRIVE

POPULATE TRACKING BOARD

NO MEDS IN RN

PROTOCOLS

BEDSIDE REG.

No way to track patients who

arrive but don’t return clipboard

LEVELS ACUITY

PEDIATRIC VOLUME= 10,000/yr

* Need Data on throughput in part of bedside triage

* = Not 24 Hour Coverage

* Collect # of patients that are repeat = _____________

* # of Patients discharged from Triage = ___________

Unassigned = 2.9%

0=0.1%

1=0.4%

2=20.0%

3=58.4%

4=16.6%

5=1.6%

Security at ED is a roaming position.

Not always at desk

Medic at front desk steps away to do transport or EKG leaving desk w/o

clinical team member

ED LOBBY-SECOND FLOOR

Wheelchair storage not as

close to door as possible

Not everyone knows to fill

out clipboard

Volunteers disconnected from

other staff

Volunteers

• Provide Information to family

• Transport (on tracker or via phone)

• Clinical Setup• Goal 2/day• To assist staff (if not available, the RN or Medic transports)

Security

• Not stationed in ED• Monitor back at position• No longer badge visitors• Transports• 12Hr coverage (Sheriff covers other 12 Hrs)

• +- 25% seated in waiting room (might be less)

No badge for visitors makes

access to acute area tough to

monitor

Some visitors wait at check in

desk, but only needed to see a

volunteer

MID LEVEL & TRIAGE RN

PROXIMITY IS GOOD

ED ENTRY

Triage RN * Triage RN* Mid level* Phlabotomy* Medic

* Security

* Volunteers 9am-9pm 7 days/wk

Minor Care & Mid level RNs

* Registrar until 11pm * Medic until 7pm

Triage 2 Station Room has no

privacy for patients

57,000 VISITS/YEAR

LESS SEASONALITY THAN PAST YEARS

157 PATIENTS/DAY RECENT TREND

IRMC ED Arrival CURRENT STATE MAP5.22.2014

IRMC Emergency Department Data Collection Date:

Patient #:

Patient Arrives Notes:

Registration Complete ESI Level?

Begin Vitals

Vitals Complete Wheelchair necessary? Y / N

Begin Triage Vitals completed during registration?

End Triage Y / N

Comments:

Patient in Room

IRMC Emergency Department Data Collection Date:

Patient #:

Patient Arrives Notes:

Registration Complete ESI Level?

Begin Vitals

Vitals Complete Wheelchair necessary? Y / N

Begin Triage Vitals completed during registration?

End Triage Y / N

Comments:

Patient in Room

1 2 3 4 5

TIME

1 2 3 4 5

TIME

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care areas. Acute patients moved directly to the treatment area for bedside triage and registration. Similarly, patients suitable for urgent care moved directly to a small zone to wait and see a provider. Only patients that could not easily be assessed moved to the Rapid Medical Evaluation area. This expanded triage that allows for discharge if appropriate, limits the longer medical screening to only those patients who need it.

The team quickly realized that by using their existing fast track area for rapid medical evaluation and using the existing triage rooms for the urgent care patients, they could implement their improved process with very little construction. Plans to convert the former volunteer desk into a results waiting lounge for the RME patients can be completed if the future process provides the anticipated results.

SUMMARIZING CONTINUOUS IMPROVEMENT

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 members of our team to be agents for good change. We have re-designed our design process using Lean as a foundation for a unique Process-Led approach that better meets the needs of today’s healthcare organization. We believe the trans-formative improvement that leading health systems, who have embraced Lean and other improvement approaches, have achieved is equally applicable to architecture.

Who We AreARRAY-ARCHITECTS.COM

We Are Healthcare Architects

We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most.

This focus makes us leaders in our field. There’s a degree of compassion, empathy, and sensitivity that goes into every project that we touch. It’s designing a nurse station with sight lines to every patient. It’s building a Behavioral Health facility without corners, so that patients are safe. It’s translating the operational needs through the technical details to fine tune the lighting system in a neonatal unit so caregivers can match the lighting to each baby’s stage of development. It is a deeper understanding, honed through relationships spanning

decades.

Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.

Array’s Knowledge Communities

We believe strongly in sharing our expertise and knowledge with others. We invite you to explore each of our thought leaders and share your thoughts with the healthcare design community.

Click here to visit our Thoughts page.

Click hereto view our thought leadership on rapid lean design events

Arrival

• Patient presents at ED entry

• Access to wheelchair

Wait

Acute

X Ray Labs

Provider

Sub Wait

Quick

Registration• Pivot RN• Name• DOB• Chief Complaint• Phone #• Find Existing Patient Record

• Visual Assessment

Rapid Medical

Evaluation• RN Assessment• Vitals• Need List• Review Symptoms• History• Suicide Screen• TB Screen• Begin Protocols

Urgent Care

• Registration• Mid level Provides Assess

• Vitals in Room

Registration

• Full Registration• Payment

Urgent Care Treatment

• Mid-Level

Sub-wait

Lewe

Registration

Discharge

Discharge

Outpatient Pavilion entry causes

confusion; safety issue

No consistent person/role to

call

ED DOOR/ FRONT DOOR/ OPP DOOR

RAPID RESPONSE

BACKER ACT/ PRISONER/ INJURY

AMBULANCE LOW ACTIVITY

Security at ED is a roaming position.

Not always at desk

ED LOBBY-SECOND FLOOR

ED ENTRY

Pargon access to Primary MD ? not

open to RNs

More Primary MD to RN

Assessment or Reg. at bedside

Bedside Reg. & payment for all patients except

urgent care

Need to identify space for regist.

startNeed to

add Non-ED Registration After Hours

Roaring? Registrar

Wait in Main Waiting Room

Use Exist Triage as Urgent Care

Develop Registration/

Check out area in Waiting

IRMC ED Arrival FUTURE STATE MAP6.11.2014

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