Until recently, two things were standard in the emergency department (ED) at Camden-Clark Memorial Hospital in Parkersburg, West Virginia:
Today, the 273-bed community hospital with a Level 3 trauma center has a new policy. Once ED patients are evaluated, anyone who is ambulatory awaits test results or discharge in a nearby “disposition area” furnished with comfy chairs and a TV. “Now we keep vertical patients vertical,” says Jennifer Price, RN, Clinical Nurse Specialist, “and that helps relieve back-ups when we’re busy.”
The “aha” moment came after Price participated in a training exercise that helps emergency department professionals practice principles of “lean” health care. Based on concepts that have cut costs and improved quality on Japanese production lines for decades, lean health care seeks to identify and eliminate wasted time, effort, and resources, leaving only streamlined processes that add value at every step.
The all-day session that proved a turning port for Camden-Clark took place in St. Louis in November 2007, and was sponsored by the Institute for Healthcare Improvement (IHI) as part of its Learning and Innovation Community on Operational and Clinical Improvement in the Emergency Department. Price and a colleague were participants in one of the five hospital teams participating in the training, led by Charles Noon, PhD, a professor at the University of Tennessee’s Center for Executive Education, and Jody Crane, MD, MBA, a former student of Noon’s and an IHI faculty member. Dr. Crane is also an emergency physician at Mary Washington Hospital in Fredericksburg, Virginia.
The instruction was book-ended by two simulations of “a day in an ED.” Each mock event took place in the same large conference room, with tables placed at various locations to represent exam rooms, labs, reception and triage areas, supply closets, and other components of a 12-bed, 14-exam-bay emergency department. Standing in for real patients were numbered pieces of paper listing a “chief complaint” and containing spaces to time-stamp the patient’s arrival and the completion of each encounter with staff, labs, and supplies.
Participants had studied lean techniques earlier as members of the IHI Learning Community, but the instructors offered no directions or opportunity for pre-planning before the morning simulation. To help physicians and nurses deepen their perspectives on one another’s jobs, they were required to switch roles as they moved each paper patient through the sequence of events suggested as the best course of action by the indicated complaint.
With seconds representing minutes, timers measured how quickly participants were able to process their patients, while new ones kept arriving every few seconds. When more than 14 patients were backed up in the waiting room, timekeepers marked every additional patient as “LWOBS” — Left Without Being Seen. Frustration mounted, as inefficiencies steadily compounded one another. “There were bottlenecks everywhere,” recalls Price. “We had no way to signal when lab tests were done or when a room was empty and, meanwhile, more patients kept coming.”
At the end of the first simulation, Noon and Crane led a discussion of how lean methods could have improved performance and boosted patient and staff satisfaction. With those ideas in mind, participants formulated an action plan to guide the afternoon simulation. They decided to form teams, identify individual responsibilities, standardize responses, consolidate supplies, sequence events, and create external signals.
Even before the afternoon session, the training had already begun to bridge the gap between lean theory and practice for Jeff Berg, RN, BSN, TNS, Emergency Department Educator for Rockford Health System in Rockford, Illinois. “The simulation embodied the difference between a classroom lecture and a psycho-motor experience,” explains Berg, whose ED is at Rockford Memorial Hospital, a Level 1 trauma center designated to lead health care disaster response in northern Illinois. Berg says the simulation helped him gain a better appreciation of team dynamics and “a better understanding of how to bring others on board.”
The simulation also impressed Lawrence Cheng, MD, the emergency physician at St. Paul’s Hospital, a 500-bed academic medical center in downtown Vancouver, Canada. “I understood conceptually what the inefficiencies are and how they affect us, but the compressed time amplified everything,” says Cheng. “It produced a visceral reaction. My understanding of how to optimize the way we do our work became much more personal.”
And that, says instructor Jody Crane, is the essential take-home message of the training. “These experienced professionals teach themselves that they don’t have to accept things the way they are. They can create better ways and, once they do, they will get better results.”
For the afternoon run-through, the leaders also included another wrinkle: participants, who were still in switched roles, were not allowed to speak. They had to rely exclusively on the non-verbal cues and standardized processes devised during the previous discussion period. Despite the vow of silence, the redesign produced much greater efficiency than the morning simulation. Participants were able to process 75 patients out of a possible 100, rather than the 50 processed earlier. Participants were able to improve their productivity and efficiency by 50 percent with fewer resources and a better, safer work environment. “When we do a third simulation, which incorporates flow concepts which are central to lean thinking, we sometimes process up to 90 patients,” says Crane. “The record is 94.”
Sue Gullo, MS, RN, the IHI Director who was overseeing the ED Learning Community at the time, says that emergency departments provide an especially rich environment to benefit from lean health care. “Staff can refine their experience through rapid learning cycles, taking out more and more waste from the ‘easy cases,’ leaving more time to cope with the not-so-easy ones.”
Indeed, Lawrence Cheng from St. Paul’s in Vancouver, along with the hospital’s ED Operations leader, Wendy Scott, RN, have already sharpened their thinking on “segmentation” ― sorting patients according to their needs. The hospital has added a Rapid Assessment Zone to its triage procedure, meaning that patients with very minor needs ― a prescription renewal, a dressing change ― are quickly served, keeping them entirely out of the main system. Ambulatory patients with somewhat greater needs ― the “walking wounded” ― are already fast-tracked to a separate area with its own dedicated staff, including an LPN, two RNs, and one MD, “but now we’re considering a ‘super-track’ designation,” says Cheng, “which would be a sub-set of fast-track patients who don’t require any procedures or testing, such as most headaches or dental complaints.”
Another efficiency being considered at St. Paul’s is parallel care. In place of the current step-by-step method of triage, registration, followed by a nurse’s assessment, followed by a physician’s assessment, “we are going to try collapsing some of these steps by maybe combining triage and registration into one step or conducting nurse and physician assessments at the same time,” says Cheng.
At Rockford, the principle focus of change in the ED has been the Express Care unit for non-urgent problems such as wrist or ankle sprains or simple lacerations. Despite best intentions, says Jeff Berg, the four-bed unit was far too dependent on the main ED. “There was no dedicated waiting area, registration, or even staff. We drew everything from the main ED. The closest physician sat about 30 feet away.” The newly redesigned Express Care space has only three beds, but its own registration/discharge area, waiting room, and supply closet. There’s a nurse assigned exclusively to this unit and by June 2008 there will be a dedicated physician as well. During a one-week measurement period in February 2008, the redesigned Express Care unit produced shorter-than-usual waits for patients and no patients left without being seen, says Berg.
Smaller efficiencies have also been tried ― though not officially adopted ― in Express Care, such as getting rid of the bed pillows. “These patients don’t need them and it takes 30 seconds to change a pillowcase for the next patient,” says Berg, “so by eliminating pillows, every 30 patients or so, we could save 15 minutes, which is enough time to see an extra patient.” Another time-saver might come from the dispensing of medications, says Berg. “Instead of giving patients their first dose, along with their prescription we could just give them the prescription unless there’s an urgent need, for pain-killers for instance.” This would mean that, most of the time, the nurse wouldn’t have to fetch the medication or record the event in the patient chart.
Possibilities for lean efficiencies in the ED are almost limitless, says IHI’s Sue Gullo. She provides some other examples:
- Visual aids such as neon-colored band-aids to show that a patient’s blood cultures have been drawn or paper flags that signal the arrival of test results;
- Materials management, including centrally located supply closets for less commonly used supplies and pre-assembled equipment carts for frequently performed procedures so they can be stored near their point of use;
- Standardization that leads to treatment guidelines for specific complaints (protocol checklists); and
- Load-leveling or coordinating staff schedules to correspond with demand, and balancing workloads among nurses, technicians, and physicians to enhance flow.
Of course, says Gullo, all EDs are not the same. Individuals have to drill into their own operations to locate their particular inefficiencies. While lean thinking can be learned, says Gullo, “it’s not really taught. It’s more ‘realized’ as the basic principles of eliminating waste and maximizing value are internalized.”
05/22/2008
