Emergency Department Prescribes Lean For Process Improvement
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DESCRIPTIONEmergency Department Prescribes Lean For Process Improvement
- 1. Making the Case for Quality May 2008 Emergency Department Prescribes Lean for Process Improvement by Janet Jacobsen On a blustery winter night a young family brings their 6-year-old daughter to the emergency department At a Glance . . . (ED) at Mercy Medical Center. The parents suspect the girl suffered a broken finger while roughhousing with her younger brother, and now they are hoping for prompt medical attention so they can return home With emergency department quickly. If this scenario had occurred just a few years ago, the family may have experienced a long, patient satisfaction scores frustrating wait, with treatment for their daughters injured finger delayed while ED staff attended to more slipping into the unhealthy serious cases. But now, thanks to process improvements through lean, the young child will likely receive 30th percentile, leaders at Mercy Medical Center timely treatment and the family will be heading home in approximately one hour. wrote a prescription for process improvement that About Mercy Medical Center would ultimately reduce the length of stay for patients For more than 100 years, Mercy Medical Center in Cedar Rapids, Iowa, has delivered The Mercy receiving emergency care. Touch by partnering the latest technology with compassionate and high-quality patient care. Mercy is The therapy was lean, and a fully accredited, 445 licensed-bed regional hospital that was founded in 1900 by the Sisters of Mercy. satisfaction scores quickly Today it offers a wide range of patient care services, with strengths in cancer care, surgical services, rose to the 95th percentile emergency services, cardiac care, critical care services, womens services, and obstetrics. Mercy is the after a cross-functional team completed value stream only hospital in the eastern Iowa corridor to offer all-private acute patient rooms. mapping to identify and eliminate non-value-added The hospitals ED is fully staffed 24 hours a day and is completely equipped with state-of-the-art tech- steps in the department. nology to handle the most serious healthcare emergencies. Mercys ED is designated as a Level III From the initial mapping trauma facility. Patients are cared for by full-time staff physicians who are board certified in emer- came a series of lean cycle gency medicine and by specially trained nurses. change initiatives, one of which led to the creation of Heeding the Call for Lean Mercys Fast Track service to treat less acute patients in one hour or less. At the time when Mercys ED was struggling with patient satisfaction scores that were sliding into the 30th percentile, as measured by Press Ganey Associates, the hospitals executive leaders were beginning By improving process flow, the capacity to to hear more about the benefits of lean. Prominent organizations in this east central Iowa community serve patients increased, eagerly shared their successes with lean and encouraged the hospital to embrace it as well. In the fall of and the department soon 2004, Mercy participated in the training and report out of a trial sponsored by the University of Iowa experienced a 6% growth and the Iowa Business Council. This test included training on lean concepts and guidance in conduct- in patient census. ing a lean event at the hospital. Convinced that lean could indeed work in healthcare, Mercy began looking for an area on which to focus its first efforts. Given the opportunities for improvement, hospi- tal leaders selected the ED for the first value stream mapping event. Initially, some employees thought that lean tools were applicable only in manufacturing environments, not healthcare. Thus, selecting team members for the first lean event was a careful, considerate process, explains Kimberlee Haskins, director of organizational development at Mercy. We worked hard to select the right formal and informal leaders. We felt if they could have a good experience with lean The American Society for Quality www.asq.org Page 1 of 4
- 2. quick look at the map reveals a number of red boxes, which were then they would go back and share those positive experiences with their departments. ultimately target areas for process improvement. Selecting a cross-functional team and providing ongoing and For Pospisil, executive support during the first value stream map- consistent communication were keys to a successful start to ping event was crucial. Tim Charles (CEO) spent more time there Mercys lean journey. One of the crucial things about lean is than I did. It was remarkable to have that commitment coming having all the key players at the table because you need the buy- from the top of the organization. With the CEO present, you have in of other departments, remarks Dr. Mark Pospisil, medical the ability to make change happen, Pospisil emphasizes. director of the ED. He explains that earlier improvement efforts typically fell short of expectations because they were conducted Focusing on the goal of reducing patient length of stay in the in isolation without participants from the lab, radiology, or other ED, several additional lean cycle change initiatives were con- departments that routinely interact with the ED. ducted in 2005 and early 2006 on the following topics: Haskins, who served as the facilitator for the value stream event, X-rayturnaroundtimes along with other hospital leaders educated Mercy employees about: FastTrackservice(seesidebar,OntheFastTrackto Success) Howleanwouldwork Insurancedenials Howleanwouldhelpimproveprocesses CTscans Whattypeofresultstoexpectfromlean Howleanwouldhelpstaffdotheirjobsmoreefficiently In some cases, issues detected during the initial value stream mapping were quickly and easily addressed. Examples of these And, most important for gaining employee buy-in, leaders reiter- do its include: ated that no one would lose his or her job as a result of lean. Ensuringthatphysicianscompletechartingwithinthreedays Teaming Up to Streamline Processes Cross-trainingofEDtechnicians Makingchangestothesoftwareusedduringthedischarge During the two-day lean value stream event in the ED, a process cross-functional team mapped the current state, identified non- Updatingproceduressothatsometestsareconductedinthe value-added processes and issues, and then developed an ideal ED rather than transferring the patient to another department state and a future state for the department. This initial work took Registeringpatientsatthebedside place in February 2005. The team also brainstormed ideas for Initiatingteamworkactivitiestopromoteaculturechangein improvements and created a list of events, projects, and do its, the department which are items that are quickly and easily corrected. When early modifications were made to ED processes, some Figure 1 shows the first section of the initial map of patient flow employees resisted the changes, recalls Chad Ware, RN, program through the ED. Red boxes indicate non-value-added activities coordinator in the ED. At first, each time we changed something, while value-added activities are designated by green boxes. A Figure 1 ED Patient Flow & Revenue Cycle Current State (abbreviated version) Greeter Triage RN Registration Waiting Room Assign to Room Room RN 2nd Assess Trigger: Pt walks in Trigger: Blue slip or Trigger: To reg desk Trigger: Charge RN Trigger: Take to room Trigger: Chart up the door walk in door Done: Reg complete assigns room Done: In room RN/PS Done: To triage Done: Pt to exam Flow Time: 7 min Done: Same Flow Time: 15 min Done: Chart up MD Flow Time: 30 min room Touch Time: 7 min Flow Time: 22 min Touch Time: 15 min Flow Time: 15 min Touch Time: 2 min Flow Time: 10 min No. of People: 1 Touch Time: 35 sec No. of People: 1 Touch Time: 15 min No. of People: 1 Touch Time: 10 min Travel Distance: 3 ft No. of People: 1 Travel Distance: No. of People: 2 Travel Distance: 20 ft No. of People: 3 Yield: 80% Travel Distance: 84 ft 148 ft Travel Distance: 0 Yield: Travel Distance: 30 ft Yield: 98% Yield: 98% Yield: 75% Yield: 98% Protocols MD Assess Tests Treatments Disposition Admit Transfer Trigger: Chart up MD Trigger: Ordered Trigger: Ordered Trigger: All results Trigger: Call for room Trigger: Consultant Done: Exam done Done: Results back Done: Complete back Done: Pt to room accepts pt Flow Time: 30 min Flow Time: 90 min Flow Time: 75 min Done: MD dc's pt Flow Time: 60 min Done: Pt to facility Touch Time: 10 min Touch Time: 10 min Touch Time: 45 min Flow Time: 15 min Touch Time: 20 min Flow Time: 60 min No. of People: 1 No. of People: 2 No. of People: 5 Touch Time: 5 min No. of People: 6 Touch Time: 20 min Travel Distance: 0 Travel Distance: Travel Distance: 0 No. of People: 1 Travel Distance: No. of People: 10 Yield: 90% 120 ft avg. Yield: 95% Travel Distance: 0 Yield: 99% Travel Distance: Yield: 90% Yield: 99% Yield: 99% The American Society for Quality www.asq.org Page 2 of 4
- 3. staff were resistant; they didnt want to work on the days when the hours, which for many U.S. hospitals is the amount of time that process changes were to go into effect. Ware says that once the patients wait just to be seen by a provider. And, along with the staff could see the positive effects of the updated processes, they impressive gains in customer satisfaction results, the department got on board quickly and were very supportive. experienced a 6% growth in number of patients served. As more and more ED staff participated in lean events they Process mapping activities also led to the following changes, all began developing a sense of pride and ownership about the of which helped reduce patients length of stay in the ED: process improvements in their de...
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