Children’s Emergency Services CES Current State and Opportunities for Improvement Final Report April 18, 2017 IOE 481 Team 2 Gagan Gupta, Anavir Shermon, Emily Smith, Hailey Willett

Focus on quality care of patient while maintaining patient safety Process Arrival Assessment Treatment Disposition Planned/Unplanned Arrival Safe/Unsafe ID Band/Severity Level Triage Nurse Primary Nurse Resident/Attending Physician Order diagnostic tests Treatment by physician/nurses Treatment by consultant Discharged Admitted for observation or inpatient care Other (transfer to OR, expire, etc.) Overall Goal of CES Focus on quality care of patient while maintaining patient safety

Key Issues Diversion from procedures due to required impromptu decision making & frequent distractions Nurses and physicians are often overwhelmed due to variability in arrival patterns Requirement to bypass standard process when high acuity patient arrives causes chaos. Unable to gauge acuity of patients due to inability to communicate Nurses spend longer than necessary getting patient background

Goals & Objectives Reduce NVA time from process steps Reduce cognitive load on staff 2 3 Improve CES Operations by focusing on Patient Safety and Quality of Care Develop detailed Value Stream Map Increase patient throughput 1 4 REMAKE THIS SLIDE Identify opportunities for improvement 6 5 Eliminate bottlenecks in process flow

Methods Gemba Walks Time Studies Nurse and Provider Survey Data Analysis Literature Review REMAKE THIS SLIDE

Gemba Walks Documentation Interruptions Inefficiencies Some triage nurses document in the room during triage, while some document after outside in the central staffing area Charting can still be happening 2-3 hours after the patient leaves Attending physicians often get interrupted by phone calls or questions Consult calls can hold up process Attending's must handle and approve all transfers Portable weight scales located far away Residents/PAs can administer full treatment depending on condition, but still need to be checked/signed off by attending Attending physician handoffs take significantly longer than primary care nurse handoffs between shifts REMAKE THIS SLIDE

Front Desk Observation Spreadsheet

Data Collection Log

Qualtrics Survey Add lesson learned for this Easier to crowdosurce (have everyone there at the same time…dont make it too complicated...remind people its not about them...everyone has different perceptions and interpretations of what the process steps really encompass

Findings & Conclusions Figure 1: Front Desk Process & Wait Times Limitations of data collection Sample Size: 106, Source: IOE 481 Team, Collection Period: February-March 2017

Findings & Conclusions Figure 2: Percentage of Triage & Primary RN Eval that occur Individually or Simultaneously Total Process Time when evaluated individually: 22 min Total Process Time when evaluated simultaneously: 15 min Key Insight Total Process Time is 37.8% shorter when Triage and Primary RN Eval occur simultaneously

Findings & Conclusions Figure 3: Nurse and Provider Process Times Sample Size: 75, Source: IOE 481 Team, Collection Period: February-March 2017

Excel Data Summary Sheet

Excel Data Summary Sheet

Excel Data Summary Sheet

Final Value Stream Map 88 min

Final Value Stream Map (Part 1)

Final Value Stream Map (Part 2) 88 min

Application of Lean in the ED Redesigning ED patient flows (Flinders) Literature Review Application of Lean in the ED (Dickson et al., 2009) Redesigning ED patient flows (Flinders) (King et al., 2006 in Australia) 1 2 Action Improved signage for directing patients. Laboratory tests/X-ray studies ordering and sending done earlier in the process Nurse, resident, and attending get the patient’s history simultaneously, reducing duplication of history and saving staff time Result Triage WT decreased from 3.18 to 2.63 mins Evaluation WT decreased from 13.68 mins to 11.65 mins Action Creation of patient “streams” for patients predicted at triage to be admitted or discharged (or fast tracked) Functional team of nurses and doctors dedicated to each stream Result Mean LOS for dischargeable patients reduced from 3.7 to 3.4 hours, and admitted from 8.5 to 7.0 hours (statistically significant) REMAKE THIS SLIDE

Figure 5: Impact-Effort Matrix Thankless Initiatives Recommendations Figure 5: Impact-Effort Matrix Quick Wins Stars Stream System Standardization of Process Steps Simultaneous Evaluation On-the-go digital documentation Impact Low Hanging Fruit Thankless Initiatives Addition of Signage Automation of Registration Process Potential re-purposing of café entrance desk Effort

Standardization of Process Steps Front Desk Triage Lab & Imaging Admittance Picture credits: (1) Icon made by Freepik from www.flaticon.com

Low Acuity Stream (Fast Track) Stream System Assigned nurses, attendings, and residents focus on quick turnover of dischargeable patients Shared resources, staff, and rooms as needed High Acuity Stream Frees resources, staff, and space for high acuity patients, and will reduce overall LOS for all patients Screener Nurse predicts whether patient will be admitted or discharged Icons by Roundicons and Popcorn Arts on www.flaticon.com Low Acuity Stream (Fast Track)

Stars Online app and/or multiple automated stations for transfer patients, referral patients, and low acuity patients to check-in rather than wait in queue Concurrent diagnosis of patient by nurse, resident, and attending to minimize repeated gathering/transfer of medical history Icons by Roundicons and Popcorn Arts on www.flaticon.com

Measurement of Wait Time Future Directions Disposition & Discharge Diagnosis & Treatment Measurement of Wait Time Picture credits: (1) Icon made by Freepik, Icon Works, and Madebyoliver from www.flaticon.com

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