Case Study: Indian River Medical Center

CASE STUDY

CLIENT: Indian River Medical Center Vero Beach, FL

Understanding the unique needs of a facility and its population are critical to developing the best solution.

In communities with limited choices, emergency departments serve many roles. Understanding the unique needs of a facility and its population are critical to developing the best solution. One size no longer fits all. We employ lean operational improvement strategies to help each client focus their resources to achieve the greatest impact.

SERVICE: Transformation

EXECUTIVE SUMMARY

METHOD: Value Stream Mapping

Value stream mapping is a lean tool used to help clients quickly assess their current condition, map patient flows impacted by the process, identify areas for improvement or streamlining, then establish an ideal future state. The future work flow is the critical first step to create a viable and sustainable project.

Challenge A fractured check-in and triage process that evolved over time left patients waiting in long queues and sharing private information in the open lobby. Safety and length of stay concerns prompted Array to suggest a complete throughput analysis before developing front door renovation solutions.

Through a multidisciplinary workshop, often consisting of two or three sessions, a cross-functional team gathers to solve a specific problem. When appropriate, data is collected between sessions to focus improvement activities.

We began this project with current state process mapping and observation. Seeing how the system operates, we can understand where bottlenecks and system failures might be occurring. The mapping session highlights discrepancies between how the system should operate, and how it is actually working.

Solution

Data collection helped pinpoint the areas where the team believed a problem might

After careful data collection and process analysis, an improved future state process was developed and implemented with only minor space reconfigurations. The facility was able to test the process in their current department to be sure it would drive improvement before expending capital dollars.

data, we used future state mapping to design an improved patient flow, which

PROJECT HIGHLIGHTS

be occurring, and helped them determine the root cause of the issue. After collecting

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involved developing a split-flow model, rather than traditional triage.

Array developed a transformation plan so the team knew which changes were necessary to turn the newly designed future state into reality. With help from process improvement experts, the emergency department team was able to improve their waiting times in a small space, with very little construction.

PROCESS TIMES COLLECTED

4

DATA SOURCES PROVIDED INSIGHT

3

SPACES RE-PURPOSED TO FIT NEW PROCESS

Client Profile INDIAN RIVER MEDICAL CENTER VERO BEACH, FL Indian River Medical Center is a widelyrecognized leader in providing exceptional, evidence-based, patient-centered care.

An integral part of the healthcare community, IRMC is well known for their award-winning Duke-affiliated Heart Center, comprehensive cancer program, and nationally-recognized vascular surgery and orthopedic services. The hospital boasts a modern emergency department, a state-of-the-art wound healing center, and a maternity wing that welcomes more than 1,200 babies into the world each year. www.indianrivermedicalcenter.com/

CURRENT CONDITIONS A community hospital serving a large indigent population sees over 57,000 visits a year. While their facility was expanded and redesigned in 2004, the physical space and its care model were no longer serving the needs of the community. Attempts to speed care time led to additional clinical steps at check-in that created difficult privacy situations. Silos between registration and clinical providers (software and staff) compounded the gaps and duplication in information gathering.

While the ED used a traditional fast-track model, all patients were screened identically through traditional triage. Efforts to shorten stays for low acuity patients were wellaimed, but the non-standard work caused unpredictable delays at triage as well as patient dissatisfaction.

Facing the same economic pressures as all emergency departments, the hospital wanted to offer urgent care style services within the ED and improve their ability to funnel patients to the most appropriate provider, while capturing payment at the appropriate time.

Through analysis of current-state data and a careful review of emerging care models in other facilities, we worked with a multidisciplinary stakeholder group that included providers, administrators, volunteers and supporting services to develop an improved future state that could leverage the existing architecture.

PEDIATRIC VOLUME= 10,000/yr

Method

IRMC ED Arrival

No consistent person/role to call

CURRENT STATE MAP 5.22.2014

Outpatient Pavilion entry causes confusion; safety issue

ED LOBBY-SECOND FLOOR

ED DOOR/ FRONT DOOR/ OPP DOOR

LEVELS ACUITY * Collect # of patients that are repeat = _____________

Unassigned = 2.9%

* # of Patients discharged from Triage = ___________

0=0.1% 1=0.4% 2=20.0% 3=58.4% BACKER ACT/ PRISONER/ INJURY

4=16.6% 5=1.6%

RAPID RESPONSE

VALUE STREAM MAPPING Mapping the value stream from customer request to completion is one of the best ways to determine whether your system is providing value to the customer. The small number of steps in their process that the customer actually values often surprises organizations that perform this activity. Value stream mapping clearly depicts the interactions between departments and technology platforms, and the process times associated with each step.

LESS SEASONALITY THAN PAST YEARS

Triage 2 Station Room has no privacy for patients

157 PATIENTS/DAY RECENT TREND

Emergent Distress

CURRENT CCTV CAMERA VIEWS DRIVE

• Immediate Triage Assessment • Registration comes to Triage Room or get info from family

Arrival • Patient presents at ED entry • If needed, staff brings a wheelchair to car

Medic at front desk steps away to do transport or EKG leaving desk w/o clinical team member

No security monitor in Triage

Medic not always at front desk

• Medic places chart in plastic bin or gives to RN

(ALL ON CLIPBOARD)

No way to track patients who arrive but don’t return clipboard

Return Clipboard

Vitals if Medic

• Patient gives clipboard to registrar • Registrar creates an account and checks existing acct. +/- 2 min • Ask have you been a patient before • Ask for SSN if can’t find record (not often) • Print labels • Arm band patient • Paperclip check in form and labels and give to Medic

• Sometime during quick registration • BP, Pulse, Respiration, Weight/Height (ask only) • Ask chief complaint • Visual Assessment

Not everyone knows to fill out clipboard

Mass of patients crowd desk with clipboards

Privacy Issue

Length of quick registration can delay Triage documentation

New requirement to list admitting Dr. at time of registrastion causes longer accounts creation and its corrected later

Wait

EKG • Chest pain patients • Medic does EKG • EKG walked to MD for review

No PC in rooms

Room

Chart to Triage

POPULATE TRACKING BOARD

• Name • DOB • Scan Photo ID • Chief Complaint • Do they have an MD?

Verbalizing chief complaint has privacy issues

Wait

• Call to assign patients to rooms for bed side triage if rooms are open

Quick Registration

Wheelchair storage not as close to door as possible

Might delay flow

Triage RN Calls Charge RN

Triage (+- 2-3 min) • Vitals if not complete • Review chief complaint • Review Symptoms • History • Med rec if volume low • Suicide screen • TB screen • Begin protocol if no room available • Call charge RN to assign room • Labs only if protocol started • Sometimes to Xray/ orders if in protocol

NO MEDS IN RN PROTOCOLS

No minor care waiting

* Registrar until 11pm * Medic until 7pm

Bedside Reg does not always occur before visit ends

BEDSIDE REG.

Lab/ Xray/ Mid-Level Holding • Triage 3 as a holding room • Used as sub wait

Some visitors wait at check in desk, but only needed to see a volunteer

Volunteers

Registration Booth Staff notes that not having a constant security presence is a danger

Minor Care Charge RN has no visual oversight of Minor Care Room Status, but responsible for Room Assignments

ED ENTRY

• Provide Information to family • Transport (on tracker or via phone) • Clinical Setup • Goal 2/day • To assist staff (if not available, the RN or Medic transports)

Discharge

Wait

• Eval patient • Treatment • Order Meds/Tests

* Security

* = Not 24 Hour Coverage

• Bedside Triage if room open

Mid-Level

* Volunteers 9am-9pm 7 days/wk Triage RN * Triage RN * Mid level * Phlabotomy * Medic

* Need Data on throughput in part of bedside triage

Security at ED is a roaming position.

Not always at desk

Minor Care & Mid level RNs

MID LEVEL & TRIAGE RN PROXIMITY IS GOOD

57,000 VISITS/YEAR

AMBULANCE LOW ACTIVITY

• Dedicated midlevel staff & RNs MInor care also now sees patient that are level 2 and going to main ED

Concern over to discontinuation of badging

Volunteers disconnected from other staff

Security • • • • •

Not stationed in ED Monitor back at position No longer badge visitors Transports 12Hr coverage (Sheriff covers other 12 Hrs) • +- 25% seated in waiting room (might be less)

No badge for visitors makes access to acute area tough to monitor

CURRENT STATE After observing the process in action, we worked with a multidisciplinary team including nurses, patient care techs, registration clerks, physicians, and department leaders, to map the current state process and identify opportunities for improvement.

DATA A variety of data sources were used to analyze the current state. Recent financial reports along with discharge and acuity metrics provided a clear picture of the distribution of ED visits and most frequent uses/burdens on the system. We combined this readily available overall data with specific process data through the use of a simple data collection sheet. This basic form is custom created for each client and tailored to their specific current state process flow.

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End Triage

Y / N Comments:

Patient in Room

For one week, staff tracked

IRMC Emergency Department Data Collection

the overall process steps as a representative sample of patients moved through the system. This information was then overlaid on the currentstate process map to complete the picture of the existing

Date: Patient #:

Transformation

TIME

Patient Arrives Registration Complete

Notes: ESI Level?

1

Begin Vitals Vitals Complete

2

3

4

Wheelchair necessary?

Begin Triage End Triage

5 Y / N

Vitals completed during registration?

Y / N Comments:

Patient in Room

system and its pain points.

Both the throughput and the acuity distribution data revealed a bottleneck in the patients leveled as ESI 3 & 4.

This discovery, combined with the department’s recent push to bedside triage for acute patients, suggested to the group that they explore a split-flow model. To further enhance that model, they investigated adding urgent care.

FUTURE STATE The team sought to speed check-in and move patients to their point of service as

Our core mission is the same as that of our clients: improve the quality of our work, increase our efficiency, and motivate our staff to reach for success. At Array, we are establishing a culture of continuous improvement at all levels of our organization. We seek to empower team members to be agents for good change.

We begin all endeavors with a consideration of process before exploring solutions. Our team can guide your organization through pre-design, ensuring clear goal setting, target outcomes, process analysis, process design and decision support. Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.

quickly as possible while ensuring they could capture the appropriate payment.

HOW CAN WE IMPROVE FLOW?

After reviewing the data and criteria for bed assignment, the group discovered that

There are many tools available to see how work flows through a system. Value stream mapping is a strategic exercise that looks at the flow of work from customer request to fulfillment.

Process mapping focuses on detailed work flow elements and can identify non-value-adding steps that reduce efficiency and add to lead-time.

traditional fast-track was no longer proving useful.

By shifting the initial quick registration to a nurse rather than a registrar, it could be combined with a quick sort to one of three care areas. Acute patients moved directly to the treatment area for bedside triage and registration. Similarly, patients suitable for urgent care moved directly to a small zone to wait to see a provider. Only patients that could not easily be assessed moved to the Rapid Medical Evaluation (RME) area. This expanded triage allows for discharge, if appropriate, and limits the longer medical screening to only those patients who need it.

TOOLS USED:

The team quickly realized that by using their existing fast-track area for RME and

A3 Dashboard, Observation, Adjacency Diagram, Process Mapping, Consensus

the existing triage rooms for the urgent care patients, they could implement their improved process with very little construction. Plans to convert the former volunteer desk into a results-waiting lounge for the RME patients can be completed if the future process provides the anticipated results.

IRMC ED Arrival

ED LOBBY-SECOND FLOOR

Outpatient Pavilion entry causes confusion; safety issue

No consistent person/role to call

FUTURE STATE MAP 6.11.2014

ED DOOR/ FRONT DOOR/ OPP DOOR

BACKER ACT/ PRISONER/ INJURY

RAPID RESPONSE

AMBULANCE LOW ACTIVITY

Security at ED is a roaming position.

Not always at desk

Need to identify space for regist. start

Acute

ED ENTRY Need to add Non-ED Registration After Hours

Bedside Reg. & payment for all patients except urgent care

Arrival • Patient presents at ED entry • Access to wheelchair

X Ray Labs

Rapid Medical Evaluation

Quick Registration • Pivot RN • Name • DOB • Chief Complaint • Phone # • Find Existing Patient Record • Visual Assessment

• • • • • • • •

Wait

Roaring?

Registrar

RN Assessment Vitals Need List Review Symptoms History Suicide Screen TB Screen Begin Protocols

Sub Wait

Registration

Discharge

Provider More Primary MD to RN Assessment or Reg. at bedside

Pargon access to Primary MD ? not open to RNs

Registration Urgent Care

• Full Registration • Payment

• Registration • Mid level Provides Assess • Vitals in Room

Discharge

Sub-wait Use Exist Triage as Urgent Care

Lewe

Urgent Care Treatment

Wait in Main Waiting Room

• Mid-Level

Develop Registration/ Check out area in Waiting

We were able to redesign their process without redesigning their space. \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\

case study: Indian River Medical Center | PAGE 3

Discovering Your Healthcare Solutions Together We are innovators who specialize in the areas your System seeks out to leverage its valuable operational and facility resources. Array Advisors has the expertise and skills to reach beyond your milestones and provide you the decision support you need.

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