CLIENT:
Indian River Medical Center CASE STUDY
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.
CHALLENGE
EXECUTIVE SUMMARY
A fractured check-in and triage process
Value stream mapping is a lean tool used to help clients quickly assess their current
that evolved over time left patients
condition, map patient flows impacted by the process, identify areas for improvement
waiting in long queues and sharing private
or streamlining, then establish an ideal future state. The future work flow is the critical
information in the open lobby. Safety and
first step to create a viable and sustainable project.
length of stay concerns prompted Array to
Through a multidisciplinary workshop, often consisting of two or three sessions, a
suggest a complete throughput analysis
cross-functional team gathers to solve a specific problem. When appropriate, data is
before developing front door renovation
collected between sessions to focus improvement activities.
solutions.
We began this project with current state process mapping and observation. Seeing how the system operates, we can understand where bottlenecks and system failures
SOLUTION
might be occurring. The mapping session highlights discrepancies between how the
Value Stream Mapping
Data collection helped pinpoint the areas where the team believed a problem might
system should operate, and how it is actually working. be occurring, and helped them determine the root cause of the issue. After collecting
After careful data collection and process
data, we used future state mapping to design an improved patient flow, which
analysis, an improved future state process
involved developing a split-flow model, rather than traditional triage.
was developed and implemented with only minor space reconfigurations. The
Array developed a transformation plan so the team knew which changes were
facility was able to test the process in their
necessary to turn the newly designed future state into reality. With help from process
current department to be sure it would
improvement experts, the emergency department team was able to improve their
drive improvement before expending
waiting times in a small space, with very little construction.
capital dollars.
PROJECT HIGHLIGHTS
7
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
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
Indian River Medical Center is a widely-
to speed care time led to additional clinical steps at check-in that created difficult
recognized leader in providing exceptional,
privacy situations. Silos between registration and clinical providers (software and
evidence-based, patient-centered care.
staff) compounded the gaps and duplication in information gathering.
An integral part of the healthcare
While the ED used a traditional fast-track model, all patients were screened identically
community, IRMC is well known for their
through traditional triage. Efforts to shorten stays for low acuity patients were well-
award-winning Duke-affiliated Heart
aimed, but the non-standard work caused unpredictable delays at triage as well as
Center, comprehensive cancer program,
patient dissatisfaction.
and nationally-recognized vascular
Facing the same economic pressures as all emergency departments, the hospital
surgery and orthopedic services. The
wanted to offer urgent care style services within the ED and improve their ability to
hospital boasts a modern emergency
funnel patients to the most appropriate provider, while capturing payment at the
department, a state-of-the-art wound
appropriate time.
healing center, and a maternity wing that welcomes more than 1,200 babies into the world each year. www.indianrivermedicalcenter.com
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
IRMC ED Arrival
TOOL
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
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
Value Stream Mapping Mapping the value stream from customer
Medic at front desk steps away to do transport or EKG leaving desk w/o clinical team member
No security monitor in Triage
Wheelchair storage not as close to door as possible
Medic not always at front desk
request to completion is one of the best
Return Clipboard • 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
(ALL ON CLIPBOARD)
No way to track patients who arrive but don’t return clipboard
Not everyone knows to fill out clipboard
Mass of patients crowd desk with clipboards
ways to determine whether your system is
Vitals if Medic
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
• Sometime during quick registration • BP, Pulse, Respiration, Weight/Height (ask only) • Ask chief complaint • Visual Assessment
Wait
EKG • Chest pain patients • Medic does EKG • EKG walked to MD for review
No PC in rooms
Room
Chart to Triage • Medic places chart in plastic bin or gives to RN
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 • • • • •
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
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
• Dedicated midlevel staff & RNs MInor care also now sees patient that are level 2 and going to main ED
ED ENTRY
Volunteers • 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
Concern over to discontinuation of badging
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)
Volunteers disconnected from other staff
No badge for visitors makes access to acute area tough to monitor
providing value to the customer. The small number of steps in their process that the customer actually values often surprises
Current State
organizations that perform this activity.
After observing the process in action, we worked with a multidisciplinary team
Value stream mapping clearly depicts the
including nurses, patient care techs, registration clerks, physicians, and department
interactions between departments and
leaders, to map the current state process and identify opportunities for improvement.
technology platforms, and the process times associated with each step.
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. For one week, staff tracked the overall process steps as a representative sample of patients moved through the system. This information was then overlaid on the
Page 2 | Case Study
Patient in Room
current-state process map to
IRMC Emergency Department Data Collection
complete the picture of the existing 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
TRANSFORMATION
Date: Patient #:
TIME
Patient Arrives Registration Complete
Our core mission is the same as that of
Notes: ESI Level? 1
Begin Vitals Vitals Complete
2
3
4
Wheelchair necessary?
Begin Triage End Triage
our clients: improve the quality of our
5 Y / N
work, increase our efficiency, and motivate our staff to reach for success. At Array, we
Vitals completed during registration? Y / N Comments:
are establishing a culture of continuous improvement at all levels of our
Patient in Room
with the department’s recent
organization. We seek to empower team
push to bedside triage for
members to be agents for good change.
acute patients, suggested to the group that they explore a split-flow model. To
We begin all endeavors with a
further enhance that model, they investigated adding urgent care.
consideration of process before exploring solutions. Our team can guide your
Future State
organization through pre-design, ensuring
The team sought to speed check-in and move patients to their point of service as
clear goal setting, target outcomes,
quickly as possible while ensuring they could capture the appropriate payment.
process analysis, process design and
After reviewing the data and criteria for bed assignment, the group discovered
decision support. Our Lean-led approach
that traditional fast-track was no longer proving useful.
to project definition provides a clear path
By shifting the initial quick registration to a nurse rather than a registrar, it could
to the right project before you begin to design.
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
How can we improve flow?
a provider. Only patients that could not easily be assessed moved to the Rapid
There are many tools available to see
Medical Evaluation (RME) area. This expanded triage allows for discharge, if
how work flows through a system. Value
appropriate, and limits the longer medical screening to only those patients who
stream mapping is a strategic exercise
need it.
that looks at the flow of work from
The team quickly realized that by using their existing fast-track area for RME
customer request to fulfillment. Process mapping focuses on detailed work flow
and the existing triage rooms for the urgent care patients, they could implement
elements and can identify non-value-
their improved process with very little construction. Plans to convert the former
adding steps that reduce efficiency and
volunteer desk into a results-waiting lounge for the RME patients can be
add to lead-time.
completed if the future process provides the anticipated results.
Tools used: IRMC ED Arrival
No consistent person/role to call
FUTURE STATE MAP 6.11.2014
ED LOBBY-SECOND FLOOR
Outpatient Pavilion entry causes confusion; safety issue
ED DOOR/ FRONT DOOR/ OPP DOOR
BACKER ACT/ PRISONER/ INJURY
AMBULANCE LOW ACTIVITY
Security at ED is a roaming position. Not always at desk
Need to identify space for regist. start
Acute
A3 Dashboard, Observation, Adjacency Diagram, Process Mapping, Consensus
RAPID RESPONSE
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
Roaring? Registrar
• RN Assessment • Vitals • Need List • Review Symptoms • History • Suicide Screen • TB Screen • Begin Protocols
Wait
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.
Cast Study | Page 3
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Transformation, and Facility Informatics. The challenges you face are not unique, but your solutions should be. Through a partnership of Strategy and Transformation we help you achieve and sustain. Our process begins by understanding your current operations and clearly defining your system’s goals before generating options. We employ a variety of integrated methods tailored to your strategic challenges, such as process mapping; operational planning; and healthcare real estate portfolio optimization, to help position your organization for future success.
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Informatics Building Information Model management (BIM) is an enabler of most other technology trends in the Architecture, Engineering, Construction, Operations (AECO) industry, including but not limited to: sustainable design, offsite fabrication, LEAN construction, and energy efficient operations. Carefully considering how best to leverage virtual/digital representations of physical buildings can provide significant returns on innovation throughout the entire lifecycle of your facilities.
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Published: JULY 2015