1. Nicole Sutherlin Brianna Mays Eliza Guthorn John McDonough

2.  This semester our team worked on finding the root causes behind the delays in the patient flow process from the Emergency Department to the Inpatient Units.  As seniors in the Supply Chain Management program at the University of Rhode Island we used our Lean and Six Sigma training to define, measure, and analyze the issues in the flow of patients. Using the DMAIC model we will introduce and explain the issues with hopes of improving and controlling the process.

3. DefineMeasureAnalyzeImproveControl

4.  The problem we were trying to solve was inefficient patient flows from the ED to the Inpatient Care Units.  Our goal was to assist and find solutions that would help South County improve their patient flow.

5.  ED Arrival to Bed Time: patient entry into ED to bed placement  Triage to Bed: From triage entry to bed placement  ED Bed to ED physician Time: From bed placement to first visit by physician  Length of Stay: From patient entry into ED to admission or discharge.  Admission Cycle: From the decision to admit patient to the time physician physically leaves the ED

7. Triage Takes patients vitals Determines severity of medical issue Takes patients personal information Prints out necessary paperwork for chart Registration enters room Finishes Registration Process Patient signs necessary paperwork Brings Patient to ED room Physician enters Patient Room Orders any necessary tests Assess and Discusses medical issue with patient Takes patients insurance information Physician reads test results Or transport to destination necessary for tests Performs necessary test Nurse Enters Patient Room Physician places test orders into Medihost Places admit recommendation into Medhost Determines whether to discharge or admit Decides necessary steps for treatment Review Patients medical issue &reviews treatments Hospitalist enters Patient Room Admit looks into Bed board for available board Sends a bed request to Admit Registration receives beep about admission Final order is placed into Medhost Determine whether to admit, observe or discharge patient 3.57 min 5 min 10 min N/A 5 min 30 min + necessary lab time 15 min 10 min 5 min N/A 20 min Registration is informed Bed becomes available Nurse from ED calls to give report to Nurse on floor Transport is notified to transport patient 130min 15 min

8.  Time of departure from ED to admission to Frost 1 bed  Time from when patient is seen to when report is given  Time from report given to admission  Time from when admitted to arrival on Frost 1  Time between when discharge order is placed to when the patient leaves the hospital  Time for discharge paperwork to be completed  Time from when paperwork is completed to their departure from hospital

9. MEASURE

10. ED Contacts Admitting Office Frost 1 nurse calls ED Admitting office contacts Frost 1 Admitting searches bed board. Patient is either assigned to room or a room is reserved Report is given Patient brought from ED to Frost 1 bed Nurse either not ready for patient or no bed available. 5 min10 min 15 min Frost 1 assigns patient to a nurse 5 min 0 min Admission to Frost 1 D D Patient either brought up instantly or when available. Clinical nurse admits patient to room 13 min 45min 75 min 18min

11. Doc places order for patient discharge Nurse fills out discharge paperwork Case manager fills out discharge paperwork Doc fills out patient paperwork Nurse teaches family Goes over meds Patient leaves hospital 20 min15 min Calls nursing home Inform nurse patient is going home/ ask when is best time to send patient home Arrange final transportation 30 min 10 min Patient waiting for a ride 10 min 55 min 50 min D Frost 1 Discharge Best Case Scenario 5 min

12.  After analyzing data obtained in the ED and on Frost 1, we were able to locate the bottlenecks that were preventing an efficient patient flow.  Bottlenecks included: ◦ Discharge and admission process ◦ Communication  Within Departments  Between floors ◦ Computer systems (Meditech vs. Medhost)

13.  As a group we generated a list of possible solutions that we hope will be implemented.  Now that our problem causes have been determined in the Analyze phase, we have thoughtfully assembled a list of solutions that we believe will make patient flow more efficient.  We believe that if improvements are not made the system will remain inefficient and profitability goals will remain at less than optimal level.

14.  Add an extra Beeper for Registration  Create a link that sends notification to housekeeping as soon as discharge is entered into system  Sync Computer Systems: Meditech and Medhost ◦ Already in progress: SBAR Online

16.  Hiring another hospitalist  Discharge Lounge for patients that are waiting on a ride home  Notification system that immediately alerts ED when bed becomes available on Inpatient Floor Already in progress: Electronic Discharge

17. We anticipate that the future use of electronic discharge will make great improvements in the current patient flow process. The data that our team gathered showed large delays in patient flow due to the numerous documents that the doctors and nurses are required to fill out by hand. We have calculated that a significant amount of time in the documentation process will be eliminated once it becomes computerized.

18.  In the Control phase, tools are put in place to ensure that the key variables remain within the acceptable ranges over time so that process improvement gains are maintained.

19. We would like to thank everyone at South County Hospital that helped us in gathering our information. A special thanks to: ED Tom Nanette Frost 1&2 Juile Kathy Gia