Manufacturing techniques help turn ED around
LOS, patient satisfaction improve dramatically
About one year ago, the ED at Doctors Hospital in Columbus, OH, was facing what Marci Conti, RN, MBA, vice president of operations and chief nursing officer, calls "a perfect storm."
Conti, who is the vice president responsible for the ED, recalls the challenges she was facing: "Our ED was designed for 35,000 annual visits, and we were seeing 69,000 patients; our left-without-being-treated rate was 6%; [Press Ganey] customer service was in the 10th percentile; our staff opinion survey was one of the lowest in the hospital."
What’s more, she says, after steady growth, volume was declining for the first time in five years. "On the positive side, the board had approved money for a new ED, but that was two years away, and we knew we had to make the best of what we had," she says.
Today, "elopements" have been reduced from 6% to 3%; average length of stay has dropped from 220 minutes to 180 minutes; and patient satisfaction is up to the 70th percentile — all while volume has increased on average by 20 patients per day.
How did they do it? By "re-engineering" the ED borrowing lean engineering and quality improvement techniques from the manufacturing world.
This is not the first time such techniques have been used in the hospital’s parent organization, Ohio Health, explains Tom Chickerella, CPIM, vice president of process excellence for Ohio Health. "We have multiple projects going on across three main campuses in Columbus," he says.
The current initiative began following a request from Conti. "At Doctors, we met with the ED management team for about two months to assess the situation, develop issues, and try to apply successful concepts from other industries," Chickerella says.
Management engineer Karthik Venkataraman, who was part of that initial assessment, basically moved into the ED for the duration of the project. "I have an office in the ED patient care area and worked in different places: the front desk, with triage nurses, with runners to see how information and charts flowed, and also in the back at bedsides, watching nurses," he says.
One of the most valuable manufacturing tools used during the initiative was simulation — in this case, software named "Arena," from Milwaukee, WI-based Rockwell Automation.
"We wanted to make sure we understood the business as best we could," says Chickerella, "so we did a hands-on assessment of actual demand, type of patient, arrival patterns, how the staffing was managed, and how well jobs were assigned based on what came in."
Using the software, the team was able to visibly show the patient arrival patterns and demonstrate what happens on a day-to-day-basis. "You actually see visible bars of people stacking up, simulating the waiting room before triage and after triage," Chickerella explains. "It’s a very good tool for showing ED people what needs to be done."
Using the simulations, the team could plan different scenarios of staffing and process changes and see if they would work without having to take the time to actually make the changes and physically try them on the floor.
Another key manufacturing concept applied was flexibility. For example, triage had created an "A" side, for acute or more urgent care, and a "B" side, notes Chickerella. "By having all cases delineated that way, there was a chance of one side being overloaded while the other was not that busy, so we created an A-B pod: two identical sides of the ED, both identically prepared," he says. "This way, any staff person could go to either pod and be equally successful."
The whole initiative was broken down into sub-areas: front-end processing, flow, and patient safety. One goal was to minimize time from door to triage, says Chickerella. "We looked at the demand coming in, did some staffing re-allocation, and created a second triage area using existing space," he says. "We added operational standards and protocols so roles and responsibilities were understood by everyone."
Before, notes Venkataraman, the patient’s first contact was a non-medical staffer. "We changed that to an RN or a medic, which was a value-adding process and minimized handoffs," he says.
The ED already had staggered staffing, says Conti. However, a quality improvement leader ran a demand staffing pattern model, "and we were able to balance out the schedule to meet demands better," she says.
About one year ago, the ED at Doctors Hospital in Columbus, OH, was facing what Marci Conti, RN, MBA, vice president of operations and chief nursing officer, calls a perfect storm.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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