STREAMLINING FAST TRACK USING LEAN PROCESS IMPROVMENT PRINCIPLES SPECTRUM HEALTH BUTTERWORTH Publication Year: 2014

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1 STREAMLINING FAST TRACK USING LEAN PROCESS IMPROVMENT PRINCIPLES SPECTRUM HEALTH BUTTERWORTH Publication Year: 2014 SUMMARY: The purpose for designing and implementing the Rapid Assessment Zone, or RAZ, is to impact key measures directly associated with patient satisfaction by targeting the care model for moderate to low acuity patient using Lean principles for improvement HOSPITAL: Spectrum Health LOCATION: Grand Rapids, MI CONTACT: Stephanie Mullennix BSN, RN, CEN Nursing Practice Associate, Emergency Department SUBMISSION CATEGORY: Safety and Quality Flow and Efficiency Patient Experience Cost-Consciousness CATEGORY: A: Arrival C: Clinician Initial Evaluation D: Disposition Decision/Throughput KEY WORDS: Communication Crowding Door-to-Doc ESI Fast Track Frequent Flyer Lean Length of Stay Patient Satisfaction Patient Volume Queing Rapid Intake Triage Wait Times HOSPITAL METRICS: Annual ED Volume: 106,000 Hospital Beds: 838 Ownership: Not-For-Profit Trauma Level: 1 Teaching Status: Yes TOOLS PROVIDED: RIE Summary of Results Dashboard CLINICAL AREAS AFFECTED: ED Fast Track Registration Triage STAFF INVOLVED: Administrators Ancillary Departments Clerks ED Staff IT Staff Nurses Physicians Registration Staff 1

2 Innovation The purpose for designing and implementing the Rapid Assessment Zone (RAZ) is to impact key measures directly associated with patient satisfaction by targeting the care model for moderate to low acuity patients using Lean principles for improvement. Utilization of a vertical treatment concept has resulted in significant improvements in LOS, LWBS and door to doc time. Data to support continuous improvement of the RAZ concept is captured hour by hour, patient by patient with the use of lean tools such as pareto charts and process control boards. This data is evaluated in the moment by the interdisciplinary team. This process allows for the identification of barriers to support patient throughput and allows for immediate intervention. Data is also collected and evaluated through daily automated dashboards and monthly data metrics which are reviewed and acted upon by the ED leadership team. Patients, Nursing Staff, and Emergency Department Providers all benefit from the decrease in patient length of stay, diminished hallway care, and low rates of LWBS. In addition to improved patient care metrics, ED Nurses, Providers, Technicians, and Clerks have all participated and contributed to the initial planning, implementation and sustainment of the RAZ. This interdisciplinary partnership has contributed to increased staff engagement and collaboration to improve the care we provide for our patients. The purpose for designing and implementing the Rapid Assessment Zone, or RAZ, is to impact key measures directly associated with patient satisfaction by targeting the care model for moderate to low acuity patient using Lean principles for improvement. Approximately 62% of patients presenting to the Butterworth ED are ESI Level 3, 4, or 5. Patients in the low to moderate acuity range often experienced longer wait times. In an effort to improve throughput of the lower acuity patients, the RAZ Rapid Improvement Event (RIE) was designed to directly impact these metrics: Left without Being Seen (LWBS), Door to Doc Time, Length of Stay (LOS), and the Elimination of Hallway Care. The use of lean tools to implement change has allowed the Butterworth ED to make significant process changes in a minimal time footprint. A3 thinking is an organized method to understand the current state, develop the future state, track metrics for improvement and to identify the gap and waste in current process. During a rapid improvement event, A3 thinking is applied and an interdisciplinary team is pulled together for 4 days to develop and implement an experiment to impact the desired metrics. The future state is identified in way to minimize waste and add value to the patient's experience. Most importantly, lean principles are striving to create a culture of continuous improvement. This engages all members of the interdisciplinary team to make continuous improvements and quickly identify waste present in the work environment. When bedside staff are committed and able to identify waste in their daily process, the patient and the interdisciplinary team benefit from an efficient, safe, and innovative workplace. Innovation Implementation RAZ is a concept that was developed through a Process Improvement Value Stream Analysis conducted at the Butterworth Emergency Department. PLAN: A multidisciplinary team was assembled to create and implement a care model for lower acuity patients; Emergency Severity Index (ESI) levels 3, 4, and 5 (Agency for Healthcare Research and Quality, 2012). Approximately 62% of patients presenting to the Butterworth ED are ESI Levels 3, 4 or 5. A3 problem solving methods were utilized to identify waste, create the future state process, and track improvement metrics. DO: The RAZ care area consists of six treatment rooms and is staffed during peak times with 3 providers, 3 nurses, 2 nurse technicians and a registration staff member. A vertical treatment model was utilized to increase available treatment space for patients who do not require a stretcher for treatment. Providers and RN s perform joint patient assessments to increase communication and decrease rework and waste. Takt Time calculations were used to establish a goal of 20 minutes from the initial joint assessment to disposition plan. 2

3 STUDY: Lean tools such as pareto charts and process control boards were implemented to capture data hour by hour, patient by patient. ACT: Standard work was established for all members of the interdisciplinary care team to establish consistency among the care team. Timeline The Butterworth ED participated in a four day Rapid Improvement Event which included all key stakeholders in which we identified current state and future state. An experiment was developed and trailed during the four day event. Standard work was developed and written. The new care model was implemented with a go-live date of 4/15, two weeks following the rapid improvement event. Results/Evaluation Although modification to an existing care model can be challenging, Emergency Department nurses, providers, technicians, and clerks have all participated in and contributed to the initial planning, implementation, and sustainment of the RAZ (Crane, 2007). This interdisciplinary partnership has contributed to increased staff engagement (36%) and interdisciplinary collaboration in an effort to improve the care we provide for our patients and community. Patients, nursing staff, and emergency department providers all benefit from the sustained outcomes. 17.9% reduction in patient length of stay 41% reduction in hallway care 33% improvement in door to provider evaluation time 63.6% decrease in LWBS rates Cost/Benefit Analysis The total amount of LWBS savings that were recognized over FY13 and FY14 is $429,373 as a result of process improvement initiatives related to implementation of the RAZ. The cost associated with the 4 day rapid improvement event was 39,140 related to staffing costs and facilitation of the event. Although cost savings can be difficult to realize for other improvements, there has been added value by decrease the door to doc time, and a corresponding reduction in the use of protocol orders at triage, which may also contribute to additional cost reductions. Advice and Lessons Learned Implementing change and promoting a culture shift is challenging in any environment. The planning event to implement the change represents only a small portion of change process. The key to improvement is in the sustainment of the initiative and the creation of a culture that supports continuous improvement. Implementation Stabilization of a core group of staff to standardize the process was essential to the success of this RIE. The Butterworth ED is a large emergency department with 240 RN/NT's and 60 ED Providers. The process was stabilized through the commitment and compliance of the new care model by the core team during the implementation phase. After the work flow was well established, new staff were trained and certified to work in the RAZ area. Commitment The initial implementation of change requires a commitment to the process to see the benefit. It is important to stay consistent to the standard work established in the event to identify which processes truly need to be modified, and what is simply "extra noise" created by the stress of change. By allowing the process to stabilize prior to making changes that are not related to patient safety issues. Succession Planning 3

4 Culture shift can be challenging. Succession planning as a result of significant change and preparation for increased RN and staff vacancy rates is an important consideration. The Butterworth ED has experienced an increase in staff engagement on our lean journey, but also experienced increased vacancy rates initially in the process. Sustainability During the RAZ RIE the Butterworth leadership team identified key interventions to support sustained outcomes. Lean Tools o Metrics are captured patient by patient and evaluated in real time using lean tools such as pareto charts and process control boards. 1 Transparency o Data metrics are collected daily and monthly through automated dashboards and reviewed by the emergency department leadership team. o Staff receive daily updates on data metrics at team huddles and actively engage in problem solving. o Staff are able to visualize and experience the success of the team. This is achieved through data sharing and frequent updates on the improved metrics, and well as through decreased patient length of stays, which translates into improved work efficiencies for staff. Problem Solving o All members of the emergency department team including providers participate in real-time problem solving to identify barriers and support patient throughput. o Lean tools are used to log issues and track follow up. Staff are also encouraged to identify and champion improvement opportunities with the unit. Accountability o All members of the leadership team perform in the moment, on unit rounding using process improvement tools, such as kamishibai audits to provide feedback on process improvement initiatives. The leadership team has established goals for rounding and performs peer to peer audits within the leadership team to support compliance. o Bedside staff also perform kamishibai auditing to support peer to peer compliance. Next steps: process has been validated, modification of the physical structure to support the process. Increase the types and acuity of patients in the RAZ ( mid acuity) 1 Bercaw, R. (2012). Taking improvement from the assembly line to healthcare: The application of lean within the healthcare industry. Danvers, MA: Productivity Press. 4

5 *DO NOT fill out this form in your browser. Save the form to your computer and then open to complete. completed submission forms to Emergency Care Innovation of the Year Award Submission Form Was this innovation submitted to the Emergency Care Innovation of Year Award contest last year? YES NO INNOVATION TITLE: HOSPITAL: Submission Category: select all that apply Safety and Quality: Practices implemented to improve desired health outcomes through quality and safety practices. These innovations strive to decrease the prevention of harm and errors for patients and are built on a culture of safety. Flow and Efficiency: Efforts to optimize patient flow through various operational techniques including flow improvement efforts such as Lean, Six Sigma, Change Management. Strategies that strive to increase throughput efficiency and improve integration throughout the organization. Care Coordination: Practices that strive to integrate all levels of care - from pre-admission all the way through the patient's care plan. These methods use deliberation organization of patient care activities to facilitate the appropriate delivery of health care services. Patient Experience: Techniques that improve patient experience through all the different levels of patient care. These strategies deal with all touch points of people, processes, policies, communications, actions in the healthcare environment and patients' perceptions of how well these strategies are employed in the organization. Cost-Consciousness: Practices that aim to safely reduce the costs of acute care through improved efficiency. Hospital: Innovation Summary: Location: Contact: Category: (check all that apply) A: Arrival B: Bed Placement C: Clinician Initial Evaluation D: Disposition Decision/ Throughput E: Exit From the ED Hospital Metrics: Annual ED Volume: Hospital Beds: Ownership: Trauma Level: Teaching Status: Key Words: (check all that apply or add additional) Care Transitions Care Manager Communication Consults Continuity of care Crowding Discharge Instructions Door-to-Doc ESI Fast Track Follow-Up Frequent Flyer Geriatric Hand-Offs Information Systems Lean Left-Without-Being-Seen Length of Stay Medical Home Patient Satisfaction Patient Volume Queing Rapid Intake Registration Safety Net Scheduling Telemedicine Triage Wait Times 1

6 Emergency Care Innovation of the Year Award Submission Form Tools Provided: (list all any additional materials related to this tool. e.g., communication materials, Process Flow Images, additional graphs displaying results, patient information collection tools, job descriptions, policies etc.) Clinical Areas Affected: (check all that apply or add additional) access readmissions ambulatory surgery center ancillary departments anesthesiology cardiology clinics ED EMS environmental services fast track geriatric inpatient units laboratory neurology nursing home orthopedics outpatient units psychiatric consults psychiatry radiology registration respiratory therapy surgery triage Staff Involved: (check all that apply or add additional) administrators ancillary departments case management clerks clinic registration communications consult services ED palliative care team ED staff IT staff nurses nursing home administration pharmacists physical therapists physicians registration staff social workers/case managers technicians toxicologists Innovation Briefly describe the innovation/process and problem that it addresses. Background Explain how the innovation works and why your organization chose this solution over others. 2

7 Emergency Care Innovation of the Year Award Submission Form Innovation Implementation This is where you can go into more depth about the details of the innovation and how it was implemented at your institution. Describe what resources were needed to start up the innovation and what will be required to sustain it. Briefly describe your team and their role. Timeline How long did it take to implement this innovation? When did you begin the planning process? How long did each step take? Results/Evaluation Feel free to include graphs/charts and/or other attachments that display your results - submit with your completed form to urgentmattersinnovationaward@gmail.com 3

8 Emergency Care Innovation of the Year Award Submission Form Cost/Benefit Analysis Describe the breakdown of the costs for implementing this innovation and provide a comparison to the costs saving. Advice and Lessons Learned Provide at least 3 and no more than 10 lessons for the reader who might want to implement this tool at their own institution e.g., How to get staff buy-in, did this require specific partnerships to succeed? What would you have done differently? Sustainability Describe how the organization is working to sustain the results? What are the next steps around this work? 4

9 Emergency Care Innovation of the Year Award Submission Form completed submission forms and additional attachments to Include any additional information below 5