Multivariable testing cuts door-to-doc times by 24%
Approach tests several process solutions in short time
Members of the ED staff at Blount Memorial Hospital in Maryville, TN, have cut the door-to-doc time from one hour to 45 minutes, and they hope to get it below 30 minutes, following a new initiative using a process called multivariable testing (MVT).
MVT was developed by QualPro, a process improvement company based in Knoxville, TN. "What MVT does is allow you to rapidly test a number of ideas all at the same time in real world conditions," explains Joe Smith, health care director for QualPro.
The premise is to try something for a short while and see if it works or not, to achieve rapid-cycle improvement, adds Richard Hall, RN, MBA, Blount Memorial's chief nursing officer. "What they do is take 10 to 20 changes, test those through their MVT, turn those changes on and off, measure the impact, put in their own statistical refinement, and tell you which of the ideas will improve the process, which will not improve — or even hurt — the process, and which will work in combination," Hall says.
Setting goals
The initial step in the process is to establish goals; in Blount's case, they were increased efficiency and patient satisfaction. Once the goals were established, "We started brainstorming at the end of March 2005," recalls Smith. In the ED, this involved nurses, physicians, management, and clerks. In the first round, 121 ideas were suggested.
"Once we had that big list, we determined that some ideas — like adding more rooms or more staff — were not immediately feasible," notes Smith. By assessing each idea for practicality, speed of implementation, and being cost-free, the 121 were narrowed down to 16. "We implemented all of them in different combinations," Smith says. "Each round was a month, and we did a total of two months' testing."
Why was it necessary to test the ideas in combination? "Frequently the biggest impact will come from the synergy between ideas, and the only way you can discover that is to test more than one idea at the same time," Smith explains.
QualPro determined that three ideas would be most effective. The first was a 'bed ahead' process. "Any time one of the units filled a bed, the staffing office had to re-look at their unit every hour and see if they had a bed for the ED," explains Hall. "If they didn't, they had to identify where the next bed would come from, and if there wasn't one they had to document what they were going to do about it." This idea proved effective, he says, because of the mindset it created.
The second idea involved doing the IV and blood draws together. "This saves the patient a 'stick' and actually helps on overall time because you get specimens to the lab more quickly," says Hall.
The third idea involved having the ED doctors write admission orders. "Like a lot of hospitals, in the past when patients looked like they needed to be admitted, ED docs would call and have a specialist or a hospitalist come and see the patient," says Hall. "Sometimes that would happen quickly, but sometimes the other physicians were tied up." Now, he says, the ED physicians write the basic orders, send the patient to the floor, call the physician, all while the process of finding a bed is under way. "We get the admission written, and the specialist or hospitalist will finish the rest of the orders when they arrive," Hall explains.
The charge nurse for each shift was made responsible for seeing that the new ideas were carried out correctly, says Smith. "Management felt the charge nurses would hate it, but they actually said they loved it, because some of these things were what they were hoping to try," he says. "That's one of the advantages of brainstorming."
Hall agrees. "One of the strengths of this system is that you take process improvement ideas from the physicians and staff. It is yours," he says. "MVT is only a tool for implementation, but it validates the things you think will need to do to improve the process."
To better gauge patient satisfaction and to benchmark their performance using a premiere survey firm, the Blount ED decided to change to Press Ganey Associates of South Bend, IN, for its patient satisfaction surveys. "It was a tougher survey process to go through," says Hall, "but over the past 18 weeks more often than not we have been in the top 2% or 3% for EDs nationwide."
Sources
For more information on multivariable testing, contact:
- Richard Hall, RN, MBA, Chief Nursing Officer, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804. Phone: (865) 983-7211.
- Joe Smith, Healthcare Director, QualPro, Knoxville, TN. Phone: (865) 927-0491.
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