1. 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

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

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

4. References Henry Ford: Joyce (313) 916-4105
University of Michigan: Shane (734)
Detroit Receiving: Monica (313)
St Mary’s: Shane (you know where he is)
Covenant: Lynette (989)

5. 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

6. 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

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

8. Flow Charting

9. Basic Flow Charting Symbols

10. Flow Charting

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

12. Flow Chart: lab TAT

13. Xray Process

14. Flow Chart: Bed Assignment

15. Others
Trend Chart
Histogram
Control Chart

16. 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

20. LWBS

21. Ambulance Diversion

22. ED Population by Time of Day

23. Door to Needle Time
Trend Chart with Benchmarking

24. Benchmarking – Compare Data with Similar Organizations.

25. 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

26. Missed Free Throws – The Effect

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

28. Missed Free Throws – The Causes

29. Missed Free Throws – 5 Whys

30. Missed Free Throws – Root Causes

31. Fishbone: Mortality Rates

32. Fishbone: Waiting Times

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

35. Nosocomial Infections

36. Complex ED Process

37. ED Physician Chokepoint at Both Ends

38. 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.

39. Milking Cows

40. Changing Diaper

41. 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.”

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