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Often times Rapid Lean Design Events help us to redesign a process without redesigning a space. An improved future state process was developed and implemented for an Emergency Department with only minor space reconfigurations.
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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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