Southwest Washington Medical Center (SWMC), located in Vancouver, Washington has 450 licensed beds and 80,000 emergency room visits per year. Their process improvement journey started in 2007 with a core group of leaders being trained in lean healthcare operations. Several kaizen events were performed to learn and apply various lean principles. Their kaizen events were driven by the Executive Leadership identifying burning issues. And, while they believe each of these events had an impact within its specific area; they felt their efforts had a limited overall organizational impact. In 2008, things changed, as they began their journey to systematically eliminate ambulance diversion.
In 2008, SWMC went on ambulance diversion an average of four (4) hours per day. This chronic situation was in conflict with their mission to provide access to care for all residents of their community. Patients who had previously been treated at SWMC and preferred admission there were sent to hospitals upwards of 20 miles away. This was not only dangerous, as potentially unstable patients required an additional 10-20 minutes before they reached stabilizing care by trained nurses and physicians, it prevented patients from receiving care by their local physician. This caused unnecessary testing, lowered quality due to the lack of detailed knowledge of the patient’s past medical history, and placed hardship on their families. Ambulance capacity was also stretched as they were out of their normal geographic area transporting patients. Additionally, this diversion also hurt SWMC financially, as four (4) hours of ambulance divert potentially resulted in a loss of eight (8) ambulance visits, four (4) admits per day and $15 million revenue loss annually.
While it was obvious that the time on divert should be kept to a minimum, the cause of the divert status was not always obvious. Recognizing they couldn’t solve the problems and improve unless they fully understood the actual situation, leadership and staff spent seven days observing staff and interviewing them about the process from ED triage to inpatient discharge (Figure 1).
Figure 1 – The Southwest Medical Center team mapping the current state
Through their analysis of the process, it became apparent that divert was a result of multiple inefficient processes which prevented the smooth and efficient flow of patients through the system, thereby causing a great deal of frustration. A current state value stream map was developed and metrics were captured as illustrated in Figures 2 and 3.
Figure 2 – Reasons for Ambulance Diversion at SWMC
Figure 3 – Current performance data at SWMC from ED arrival to inpatient bed
The Value Stream Mapping event identified several opportunities for improvement including the lack of standardized leadership response to throughput issues. As indicated in the graph above, ED divert was most frequently called due to a feeling by the staff that they were overloaded. A Kaizen team, comprised of executives and directors, was formed in order to define the expected leadership response to divert. As a result a ‘Patient Access to Care Team’ or ‘PACT’ team, composed of an Executive/Director, was developed to be readily available 24/7 to provide support and assistance to remove roadblocks and, if possible, prevent unnecessary diversion. ‘PACT Bed Ready’ meetings were formalized to foster early identification of patient flow potential bottlenecks and cultivate creative problem solving and sharing of resources. This action had a significant and immediate impact in the reduction of divert from hours per day to minutes per day.
The ‘PACT Bed Ready’ meetings had a positive effect on timely ED admission placement; however, they realized there were other important issues, including problems with the admission process itself. One such problem was the fact that patients would sometimes wait long periods of time in the ED to receive admission assessments and inpatient orders so that they could be moved to the floor. While this problem is quite common, yet difficult to solve in hospitals across the nation, engaging in process walks with the Hospitalist physicians and gaining their perspective proved instrumental in solving the problem. During these process walks, the Hospitalists reported having difficulty finding assessment supplies on the units and noted that their job was very difficult due to the demands on the inpatient units, such as nurses calling for orders on patients who were direct admits and needed immediate attention. To reduce their own frustration and help control their environment, they began holding patients in the ED to ease their workload.
In late 2008, a group of ED Providers and Hospitalists met and revised the transition order process for all of their non-Intensive/Critical Care Unit patients to improve handoff information and reduce admission delays in the ED. The transition order is initiated by the ED Provider after they have given report to the Hospitalist. The transition order is complete enough to address the patient’s imminent clinical care needs upon admission and expire in 4 hours. By working together, the ED physicians improved flow of admissions to the inpatient units while allowing the Hospitalists ample time to evaluate the patient and initiate further orders after arrival to the unit if they are unable to keep up with the ED demand. Working as a team and understanding that flow was a hospital-wide issue meant that the ED physicians would have to assume some liability for patients while they await the Hospitalist assessment, however the groups were able to work together so that the benefit in ED flow outweighed the slight increase in risk. On the inpatient units, admission kits were established in order to eliminate hunting for equipment. When this process is followed, a significant amount of time a patient would otherwise be holding in the ED is eliminated. Upon arrival on the unit, the patient is able to get their immediate care needs met, improving patient satisfaction and outcomes while freeing up critical ED bed capacity.
With the low hanging divert opportunities exhausted, SWMC looked for outside resources to tackle the more in-depth throughput constraints within the ED. Executive, clinical leaders and ED providers attended a week-long, intense, Advanced ED Operations Course designed to train the attendees in applying lean methodology in healthcare. This formalized training better positioned leadership to understand server capacity, queuing theory and lean principles. Southwest felt this was a “tipping point” in their lean journey as the executive team fully adopted lean methodology as their formal, organization-wide process improvement strategy. A full-time Lean Sensei position was designated to the ED Value Stream and an ED Value Stream Cross functional team was established. This team was made up of ED and ancillary personnel to establish a current state and future state value stream road map.
This team began to consider their patients in terms of individual patient value streams based on ESI acuity. In their current state mapping, they recognized that the lowest acuity patients had length of stays exceeding two (2) hours and were the most likely to leave without being seen. Waste was abundant throughout the process:
- Over – processing: Multiple assessments including one at triage, one done by a nurse in the room and then by the provider.
- Waiting: Waiting for rooms & providers. It should be noted that the average time from triage to provider was 90 minutes (71% of the stay). Additionally, providers waiting for equipment such as laceration trays.
- Inventory: Patients were tying up beds waiting for lab & diagnostic testing results limiting the ability to see another patient in that room.
- Motion: Staff members were traveling outside the patient’s room to print discharge instructions, pull supplies and equipment.
- People: Some staff were idle while others were overwhelmed with tasks due to unbalanced workloads.
The Kaizen team designed an “ideal state” process flow incorporating the lean tools necessary to support an average takt time of 60 minutes utilizing three newly designed fast track rooms. Clearly defined Fast Track patient criterion was established. Streamlined documentation tools were developed including the most common discharge instructions pre-printed and available in the room. The rooms were set up with point of care supplies with PAR levels based on volumes and kanbans for ease of restocking. The activity between the nursing and support staff was analyzed and responsibilities were reassigned to ensure load leveling and one piece flow. The nursing assessments performed at triage and at the bedside were abbreviated, eliminating unnecessary information collection. The ‘ideal state’ included patients waiting in a results waiting area for testing freeing up their room for additional patients. This required designing a visual workplace to track the patient in the stay and quick alerts when the next step was completed.
Employing the concept of rapid cycle testing, a series of real life trials were held to test, debrief and revise the process with their core Kaizen team prior to full staff implementation and training. This gave the team an opportunity to revise the process and modify the inclusion criteria and hours of service. More importantly, it solidified the process and converted the skeptics. During the trials they met the goal of an average length of stay of 60 minutes and provided significant improvement in patient and family satisfaction. Additionally, 8 -10 % of the overall volume was relieved, acting as a release valve for the main ED, reducing the load and enhancing flow.
The team’s Value Stream then focused efforts on the ESI level 3 patients. They looked for opportunities to reduce the time to see a provider and overall length of stay. Two primary tactics were initiated: ‘Bed is a Bed’ philosophy and Upfront Triage Redesign.
The ‘Bed is a Bed’ philosophy focused on early provider assessment for the ESI level 3 patients. The ED was sectioned into specific areas based on patient type which led to an imbalanced capacity, thereby directly increasing patient wait times for a room. The rooms were made universal and stocked with equipment/supplies to manage all patient types with the exception of some well defined high acuity critical / trauma and fast track rooms which had supplies for these specific value streams. Exclusion criteria for specific patient types who had to go to a particular area in the ED to support this process were also established. This resulted in a 5 minute reduction in door to doc times.
With these efforts they had recognized a reduction in divert hours down to just 50 minutes per day. Due to their Level II trauma designation and Centers for Excellence in Heart and Stroke, they continue to receive all STEMI, stroke and trauma patients along with their walk-in volume, so the real impact of this strategy was questionable. At this point a decision was made to implement a No-Divert policy to start July 2010.
In preparation for the ‘No-Divert’ policy implementation, a further redesign of triage was undertaken that resulted in a major shift in how patients were assessed. In their previous system, they had an Emergency Department Technician and Patient Access staff member at the triage desk that provided a quick triage and called a nurse, if necessary, for immediate bed placement. In this system, their patients were either placed directly into a triage booth or returned to the waiting room to await a full nurse triage.
With the new model a Pivot RN is the first medical contact with the patient. This nurse provides an initial assessment and determines the patient’s track within the ED. Low acuity patients are sent immediately to the Fast Track area without an additional assessment. Emergent patients are sent immediately to a critical bed with a clinical handoff between nursing staff. All other patients are sent to a triage booth for a brief nursing assessment. The Pivot RN has essentially become the flow coordinator for the front end triage area.
A triage nurse and an ED triage technician are then responsible for the triage bays. The triage nurse is responsible for the nursing assessment including obtaining the medication list and initiating a nurse menu when a bed is not immediately available. The nurse menu was developed by the providers and allows for lab and diagnostic testing for specific chief complaints. The ED triage technician is responsible for ordering and obtaining testing such as lab and diagnostics along with transporting patients to their room based on availability.
Additionally, a volunteer greeter position and desk was set up in the waiting room to answer questions and direct visitors to the appropriate locations. This action reduced the percentage of people in line waiting to talk to the front triage personnel by 50%, offloading a critical potential bottleneck in the process. This resulted in shorter lines and more rapid access to the initial triage.
Based on volume trending, the process is currently staffed 14 hours per day and the outcome has been promising. Patients who have been interviewed have made very positive remarks and feel like they are being taken care of sooner.
Sustainment is a key challenge at this time. ED Value Stream weekly meetings including ED leadership, staff and providers, along with ancillary department representatives, are held to monitor key metrics and develop action plans. Executive support for engaging staff to develop and trial new ideas has been and will continue to be essential.
To date, audit results for the three key initiatives are at or above 90% compliant. Their recent increase in volume has added stress to their systems and new issues have surfaced. Further work will need to be done to address these new issues, realizing this is a continuous improvement journey. Strategies they hope to explore are implementing an intake model and standardizing their critical care response.
Figure 4 – Outcomes Data at Southwest Medical Center
Due to the initial successes in the ED and subsequent hospital-wide lean training sessions, Southwest Washington Medical Center now understands the patient-focused, front-line led power of lean. This has rapidly spread throughout the organization with some impressive results. Figure 5 is a summary of the continuous improvement efforts to date with in the ED at SWMC: