University of Tennessee Medical Center

In 2000, just ten years ago, UT medical Center was transformed from a manageable, more functional, 24-bed  into a sprawling 51-bed, “Mega-ED.” Prior to this expansion, the patient volumes at UT Medical Center were increasing at a similar pace as the rest of the country. Around the same time, the hospital transitioned from a state-run to a not-for-profit organization and took on a growth strategy that would prove to drive up their volume. As the region’s only Level 1 Trauma Center, volume grew across all patient types from low acuity to critical care/trauma. As this volume grew, so did the need to continuously assess and redesign their processes to meet their changing patient needs.

More recently, in the summer of 2008 a competing ED in Knoxville that saw nearly 50,000 patients a year closed. This created additional demands on the remaining 4 EDs in the city, and as a result, UT Medical Center received a sizable amount of the volume that would have gone to this facility. In one month, the volume grew by 10% compared with the same month the prior year. This created a challenge that, if not addressed immediately and deliberately, the ED performance would likely spiral out of control.

After a few months the department adjusted to the increase in volume, but a few months later during the earlier summer months of 2009 the department had again began to lose ground. As evidence, the LWOBS rate had gradually increased throughout the year from a low of 2% to a high of 4.5%. Around this time, a cohort of the hospital’s senior administration and managers completed 2-5 days of training in Lean Healthcare. Shortly afterwards, the ED Leadership received similar training which was specifically designed for the implementation of advanced lean operations in the ED. At this point, and the hospital was poised to make sweeping and sustained change with a combined approach which placed the patient as the central focus.

The team at UT Medical Center’s ED started by looking at their patient arrivals by acuity and by hour of day. This directed the team as to where they needed to focus their improvement efforts and pointed towards the proper configuration of their human and physical resources. At the time, their Fast Track was open from 12 pm to 12 am. As a result of a detailed analysis of their arrival patterns, they could see that they were missing the ramp up by two hours and twelve minutes…yep, twelve minutes. For some unknown reason their ESI level 4 and 5 patients started coming in at 9:48 in the morning. In order to properly match their demand to their capacity, it was obvious that they needed to open Fast Track at 10:00 am keep it open one hour later than they had been closing down previously. Prior to this move, their LWOBS rate was over 4.5% and the average length of stay for this area was approaching the 200 minute mark.

The Fast Track is comprised of eight rooms and a results waiting area. From analyzing the data, it appeared that the demand was sufficient to merit double coverage from 1pm to 10pm. The new model that was implemented was one RN and Midlevel at 10:00 am until 1:00 pm when another RN and Midlevel would arrive. From 1:00 pm to 10:00 pm there was then double coverage. While technically, adding resources is not a lean move, the group realized that there were practical limitations to the upper limit of throughput that could be achieved while maintaining high quality and patient satisfaction. In addition to the increased staffing, the Fast Track was also reconfigured to improved supply locations and quantities necessary to treat low acuity patients (Figure 1). As a result of their process improvement efforts, in one day their average length of stay in Fast Track was nearly cut in half and they were actually seeing patients, walkouts.  In just a few months after they realigned their capacity to their demand, their left without being seen rate was less than 2%.

Figure 1 – Lean inventory improvements in Fast Track

After implementing improvements in fast track that improved their length of stay and walkout rate of low acuity patients, the team at UT Medical Center realized that they still had significant work to do with the remaining ED patients. In order to further impact their LOS, they realized that they had to address patient segments other than Fast Track and Main. They looked at their acuity by percentage of total volume and found that their level 3 acuity was about nearly 50% of the total. They understood that a far number of their ESI 3 patients are admitted, but a far greater number are treated and released. This represented the next greatest opportunity for UT Medical Center.

UTMC’s hourly patient arrival rate showed that a majority of the low resource level three patients began arriving at 10:30 am and continued until 12:00 am. The ED is fortunate to have a six bed area adjacent to their fast track that was previously used for a variety of other things, that they realized they could modify to accommodate these level 3 patients. They creatively named the area, “Rapid Evaluation and Treatment, RE&T, or RENT” – meaning patients will be seen quickly but they don’t own the bed, hence “renting “it. With the area being close to Fast Track they realized they could utilize pooling by cohorting all of the patients in the same results waiting room.

On March 1st, 2009 the team piloted the area and had great results. The pilot was scheduled to last five days, but had such great success that they never stopped the pilot. During the pilot, the team did not have specific entry criteria to this area other than, “low resource level three acuity patients.” In the true lean spirit, the team wanted to learn who could and could not be seen in the area by trial and error.  In the pilot, they also used two rooms as intake rooms and the patient could go straight to results waiting or a treatment bed if they needed one. After a couple of weeks the process evolved into using every room as an intake room  and if the patient needed some brief treatment time in a bed, they would stay in their initial room and then go to results waiting. After a couple of months of experience, the team was able to draw some conclusions as to which parts of the processes worked best and which needed further modification. Based on experience, they revised the inclusion and exclusion criteria for the unit which has lead to more reliable patient placement and less variation. The area has been open for 6 months and has continued to show great success.

With any new process comes challenges and conflict. One of the biggest challenges the team faced implementing this new process was to concept moving patients to different locations once their care has been initiated. The team found it challenging because they had never moved a patient in the middle of their care process prior to the introduction of this new process. The concept of keeping patients vertical, while intuitive, is difficult to hardwire into culture, but the team at UTMC continually reaffirms that it is okay to move patients. Moving patients to the results waiting area has proven to be the key maximizing the efficiency of this area.

As with any implementation of change, the key is to reassess your system to determine the next most likely target. After the team implemented the RE&T process, they again looked at their lower acuity patient arrivals per hour and noticed an increase of six more patients arriving between the hours of 11:00 pm to 1:00 am than they did a year ago. Because their process had been optimized, they extended the Fast Track hours to 2:00 am. This increase in volume was indeed a validation that they had created more capacity and it had quickly filled with patients who otherwise would not have been seen or would have chose one of the other EDs in the city. The team had truly grown revenue through its process improvement efforts.

At UTMC, the Fast Track length of stay continues to remain nearly half of what it was a year ago at just over 100 minutes. Their overall length of has been reduced by 15 minutes compared to 2009 (Figure 2). Their greatest success has been reduction in patients who leave without being seen.  In the past year they have seen their LOWBS rate continue to decline and remain below 2% (Figure 3). This is in addition to the 6 additional lower acuity patients they have drawn to their facility. The team at UTMC has affirmed their assumption that getting patients to the provider is key in reducing length of stay and left without being seen rates.

Figure 2 – UTMC overall length of stay 2008-2009
   Figure 3 – UTMC left without being seen rate, 2007-2009