Process Analysis: A Tool to Improve Patient Care Jason M. White, M.D., MMM, CPE, FACEP Chairman, Emergency Medicine St Mary’s of Michigan April 17, 2008

Jason’s Big Announcement Jason Johnson, M.D.

Emergency Department Nurse Staffing Jason Johnson, MD Administration Project September 25, 2007

References Henry Ford: Joyce (313) 916-4105 University of Michigan: Shane (734) 936-6666 Detroit Receiving: Monica (313) 754-3345 St Mary’s: Shane (you know where he is) Covenant: Lynette (989) 583-6800

Summary Neither Navigant nor ENA nurse staffing ratios have appeared to work. Other hospitals aren’t including any non-RN staff in their nurse staffing ratios Strictly adjusted arbitrary nurse to patient ratio used (4:1 most popular) Custom nurse staffing ratio (Henry Ford) seems to be the most successful

Great News! From: Shane Hunt To: Jason White Date: Monday - April 14, 2008 Subject: staffing in ED Jason It seems that we were granted the 4.2 additional ftes of nursing!  ...awaiting to see if I can fill now or have to wait for July 1st. ......... so some light in out there. Thanks for all your support in making this happen.  It has been a long battle but maybe a win for our staff and patients ...at last.   Shane

Process Analysis Tools Tools – One picture (or Diagram) is worth a thousand words.

Flow Charting

Basic Flow Charting Symbols

Flow Charting

Process Flow Diagram – visualization of a process. What is happening. What should be happening. Limitation - may not identify underlying problems.

Flow Chart: lab TAT

Xray Process

Flow Chart: Bed Assignment

Others Trend Chart Histogram Control Chart

Trend Chart: Follows Event Over Time. Patient volume by month of year. Blood Cultures Prior to Antibiotics Antibiotics within 4 Hours of Arrival Radiology Turn Around Times Left Without Being Seen Ambulance Diversion ED Population by Time of Day

LWBS

Ambulance Diversion

ED Population by Time of Day

Door to Needle Time Trend Chart with Benchmarking

Benchmarking – Compare Data with Similar Organizations.

Cause and Effect Analysis: Ishikawa Fishbone Diagram Variance – lack of quality or problem.Causes Chance causes – beyond our ability to manage or control. Occur outside the system. Assignable causes – occur within the system of control. Root causes – contributory reasons for a variance within a complex system

Missed Free Throws – The Effect

Deming: 15 % of problems assignable to individuals, 85% of problems assignable to five factors: Management Materials Methods Machines Manpower

Missed Free Throws – The Causes

Missed Free Throws – 5 Whys

Missed Free Throws – Root Causes

Fishbone: Mortality Rates

Fishbone: Waiting Times

Prioritization – Parieto Chart Sort out the “vital few” from the “trivial many”. Frequency of each cause or event.

Nosocomial Infections

Complex ED Process

ED Physician Chokepoint at Both Ends

Home Work Assignment Due one week. 4/25/08 Draw a Flow Chart Diagram for some process in either your personal or professional life. Examples: getting up in the morning, ordering a laboratory test, etc. Draw a Ishikawa “fishbone” diagram for some process in your personal or professional life.

Milking Cows

Changing Diaper

Final Thoughts – Woody Allen “More than any time in history, mankind faces a crossroads. One path leads to despair and utter hopelessness. The other, to total extinction. Let us pray that we have the wisdom to choose correctly.”

Final Thoughts – Jerry Garcia “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”