LEAN Improvements to Patient Access and Flow in an Emergency Department

LEAN Improvements to Patient Access and Flow in an Emergency Department

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4 Disclosures

Objectives Explain Basic LEAN Concepts Interpret Pay for Performance Measures in Ontario Describe the History of LEAN at Queensway Carleton Hospital Illustrate examples of LEAN methodology to improve ED flow and wait times Examine future directions using LEAN to improve flow

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Definition A quality improvement methodology and management philosophy that focuses on maximizing customer value while minimizing or elimination waste and complexity in work process

A Brief History of LEAN

What is LEAN? LEAN is not... a weight loss program about eliminating jobs forcing people to work harder speeding up the work only focused on manufacturing operations only common sense finger pointing or assigning blame Source: Jeffrey Liker, Optiprise

We are trying to achieve... Lowest Cost Highest Quality LEAN is an improvement approach that can deliver sustained improvement across cost, quality and delivery Fastest Delivery

All Work is a Process Blood sample taken Label & register sample Test sample Capture results

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

Who is the Customer?

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

The Value Stream Triage Registration Assessment Treatment Discharge

Understanding the Voice of the Customer How does the patient view the process? What does the patient look at to measure their experience? Book procedure time Drive to hospital Park car Wait in lobby Register Walk to procedure area Procedure

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

Establish Flow How well can the product or service navigate through the process? What slows or stops the flow?

Establish Flow ED Laboratory Diagnostic Imaging Inpatient Unit Pharmacy Housekeeping Patient visit (value stream)

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

Principles of LEAN Value Value is defined by the customer Continuously seek new ways to improve the process Seek Perfection Value Stream The value-stream is the sequence of steps taken to create value Make or process only what the customer needs when they need it by reacting to a trigger Implement Pull Establish Flow Flow is established so that the product or service moves fluidly without interruption through the value stream

Using the Scientific Method Identify problem Collect and analyse data to diagnose cause Use structured experiments to test solutions Review the results of experiments in order to learn and/or take action PDSA

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Pay For Results (P4R) Ontario s ER wait time strategy Physician Initial Assessment (PIA) Length of Stay (LOS)

Pay For Results (P4R) 90 th Percentile Metrics (Baseline Period: 2011/2012): Metric Baseline 2013 Target* PIA 3.7 3.3 ED LOS for CTAS 1,2,3 Non Admit 7.6 7 ED LOS for CTAS 4, 5 Non Admit 5.6 4.9 *to be updated

Mental H IP ALOS (excl. ALC) of patients in Mental Health (days) N/A 7.9 10.0 15 IP Discharges by 11:00 Mental Health (%) N/A 40.0% 26.7% 40% IP Discharges by 14:00 Mental Health (%) N/A 60.0% 55.6% 70% IP Discharges Mental Health 0 0.71 1.50 N/A ALC patients Mental Health (#) 0 0.0 0.4 0 IP Discharges by 11:00 D4 (%) N/A 81.8% 42.9% 80% D4 IP Discharges by 14:00 D4 (%) N/A 81.8% 71.4% 100.0% P4R Public IP Discharges D4 0 1.57 0.93 90th Pct ED LOS for Admitted Patients (hrs) 15.7 13.9 16.8 90th Pct ED LOS for CTAS123 non-admitted Patients (hrs) 6.3 6.7 6.6 90th Pct ED LOS for CTAS45 non-admitted Patients(hrs) 4.0 5.1 4.9 90th Pct Time to Physician Initial Assessment (hrs) 2.7 3.0 3.0 90th Pct Time to Disposition to Admit (hrs) 10.1 10.9 10.9 90th Pct Time to Inpatient Bed (hrs) 5.6 4.1 6.1 90th Pct Patients with complex conditions (hrs) 6.4 7.8 8.1 90th Pct Patients with minor or uncomplicated conditions (hrs) 4.0 5.1 4.9 N/A 18.0 7.0 4.0 3.4 12.0 4.0 8 4 Metric underperforming target by more than 25% Metric within 25% of target Metric equal or outperforming target "Lacks Data" = not enough data to make calculation "N/A" = if no record matches criteria or any error happens

LEAN Team Physician, nurse, LEAN expert, Data Analyst Investment in education Staff engagement Commitment from senior administration

TRUE NORTH METRICS Safety/Quality -Preventable Mortality -Medication Errors 7/2/09 Ver. 4 People - OSHA Recordable Injuries - Turnover (voluntary & total) -HAT Scores Customer Satisfaction - Access - Turnaround Time - Quality of Time Financial Stewardship - Operating Margin - Productivity

Recognized for exemplary patient care, people and performance. Patient Safety Quality of Care Our People Our Finances Clinical Excellence Operational Excellence Access Transitions in Care Partnerships Responsive and Integrated Care and Service Patient and Family Centred Care and Service Patient Satisfaction

Recognized for exemplary patient care, people and performance. Patient Safety Quality of Care Our People Our Finances Clinical Excellence Operational Excellence Access Transitions in Care Partnerships Responsive and Integrated Care and Service Patient and Family Centred Care and Service Patient Satisfaction

Cubes Nsg Desk ACC Cubicles Rms 3-8 Resus Triage/MWR Rms 1 & 2 Obs A 11 12 ED DI MD Desk Obs B Lounge MCC Rms 9 & 10 US CT DI

Patient Volume Hours 27,500 25,000 22,500 20,000 17,500 Patient Volume and PIA by Location 25,914 4.3 Patient Volume and PIA by Location 5.5 5.0 4.5 4.0 3.5 15,000 12,500 2.6 3.0 2.5 10,000 7,500 1.9 1.7 2.0 1.5 5,000 6,461 1.0 2,500 0 3,420 3,338 0.4 108 Cubes Minor Care OBS A OBS B Resus Volumes 90th %ile PIA 0.5 0.0

Minutes Value Stream 250 CUBES Non Admit - Patient Journey Breakdown by Time (n=25,914) 200 9 15 150 119 100 233 50 87 0 Total ED LOS Arrival to Triage Triage to Reg Reg to PIA PIA to Disp Disp to Left ED 4

Analysis of Arrivals 40 Data about Non-Admits in Cubicles/Minor Care area from Jan 1 to Apr 30, 2013, for all CTAS. These are arrivals averaged over 4 months, for every hour.

Analysis of Arrivals/Departures Total Departures from Day 2 include Departures from Day 2 due to new arrivals (same as Day 1), plus the spill over from Day 1 41

Analysis of Backlog 42 Backlog is the difference between Arrivals and Departures, cumulating over time. Day 2 Arrivals, Departures, and Backlog represent the steady state at QCH ED

Previous Physician Schedule Capacity Allocation (# Physicians on floor) drive Departures. Backlog is a consequence of Capacity Allocation. It must not be the driver for Capacity Allocation; Arrivals should 43 be.

Long-term Objective with Physician Schedule Backlog is cleaned up during the night. Capacity Allocation tracks patient Arrivals. At worst, Backlog level is never greater than 2X the allocated Capacity at that time (Instant Time 44 to Clear Backlog); this means much shorter wait times.

Simulated Impact of New Schedule on Backlog Backlog is cleaned up during the night. Backlog goes up to 23 during the day. At worst, Backlog level is never greater than 4X the allocated Capacity at that time (Instant Time to Clear 45 Backlog) at 09:00. All this means shorter wait times.

Cubes Nsg Desk ACC Cubicles Rms 3-8 Resus Triage/MWR Rms 1 & 2 Obs A 11 12 ED DI MD Desk Obs B Lounge MCC Rms 9 & 10 US CT DI

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Cubes Nsg Desk ACC Cubicles Rms 3-8 Resus Triage/MWR Rms 1 & 2 Obs A 11 12 ED DI MD Desk Obs B Lounge MCC Rms 9 & 10 US CT DI

Team Model 1 Physician, 2 nurses, clerk 3 rooms

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OBSERVATION AREA 1 2 3 4 5 6 OBS A Nursing Desk 7 10 9 8

PDSA 2 trial dates implementing new physician schedule and new Team Model Concept Collected data and feedback Presented back to staff

Quarterly Report Card

Matching Physician Matched physicians in top 5 PPH with those in bottom 5 PPH

Summary Value Stream Physician and Nurses schedule Team Concept Quarterly Report Card Matched physicians Trial Dates Senior management and staff engagement Lots of change management

Wait Time (hours) Preliminary Results: ED Wait Times Project 10 ED Wait Times 9 8 7 6 5 4 3 2 90th Perc Non-Admits CTAS 123 LoS Target Non-Admits CTAS 123 LoS 90th Perc Non-Admits CTAS 45 LoS Target Non-Admits CTAS 45 LoS 90th Perc PIA Target PIA 1 0

Next Steps Consultant Response Times DI Turn-Around Times Time to Inpatient Bed Point of care testing

Special Thanks Genevieve Hourston Debbie Weatherhead Alain Mouttham Coralee Purdy Christina Duvall