Case Study #7: Make Haste, Reduce Waste: Adding Value Despite Space Constraints

EMERGENCY DEPARTMENT SETTING:

• Suburban hospital in a large Texas city
• 25,000-30,000 annual Emergency Department visits
• 9 ED rooms and 3 minor care rooms

CHALLENGE:

• Overall satisfaction had been increasing from 70% to over 90% through previous process improvement work
• However, wait time satisfaction had been decreasing and was near 50%
• Problems included rising volume & limited space
• Left Without Being Seen (LWBS) was increasing
• Rising LWBS created lost revenue, decreased patient loyalty, & patient safety concerns

EFFORTS:

• Recipe for Change in the ED:
  • Ingredients: The Team
    • Administrative leader with vision
    • Physician leader willing to seek new approaches
    • Nursing leader with will to implement
  • Directions: The Process
    • Engage team with a vision
    • Provide time for team members to participate
    • Capture data and evaluate
    • Run small tests of change to arrive at the solution
    • Celebrate success
• Goals and approach
  • Get patients to a physician quickly
  • Use limited space efficiently
  • Maintain patient safety and improve experience
  • Rapid Medical Evaluation (RME) system implemented
  • Utilized Lean mantra (create more value with less work)
  • Collected and analyzed data
  • Measured value by patient feedback
• Changes made:
  • Reduce wasted space
    • Kept vertical patients vertical
    • RME: ESI Level 4-5 (occasional 3), ENT, Respiratory, Dermatological
    • Main ED: ESI Level 1-3, Cardio, Abdominal, Gyn
    • Recognized "triage is a process, not a place"
  • Make haste to doctor
    • Minimized up front registration/triage time
    • Full registration moved to Back area/RME area
    • All nurses trained to do Quick Reg/bedside triage (for triage surges)
    • Eased triage bottle neck
    • Triage info shortened
    • Other nurses trained to do triage in parallel in the treatment area
    • Improved physician utilization - Work RME or regular ED; e.g. place professional resources at nodes of demand
• Tools for Change
  • Daily Sheets
  • Charts
  • Efficiency measures
  • Safety measures
  • Financial measures
  • Patient experience measures
  • Example measure - physician scorecards triage to doc, door to door, and trends
  • Followed weekly with PI team meetings. Discussed at monthly ED physician and nurse staff meetings. Updates also given periodically at Medical Executive Committee meetings and forwarded up the administrative chain.

RESULTS:

• Average door-to-doc time decreased from 52 to 34 minutes
• Wait time satisfaction increased from 50% to over 80%
• Left Without Physician Contact (LWPC) dropped to less than 1%
• Left Without Being Seen (LWBS) dropped to less than 1%
• Significant gross revenue generation from capturing LWBS
• Staff Buy In!!!

Figure 1. Faster Door-to Doc by Improved Use of Staff
(moved to bedside registration & triage)