CLIENT:
Orange Regional Medical Center CASE STUDY
Middletown, NY
Fully understanding the problem allows us to develop solutions that focus on the root cause. Sometimes it is difficult for staff to see what is happening beyond the confines of their reality. In this case, the emergency department (ED) was very crowded with patients waiting for inpatient beds. The ED believed they needed more treatment space, but root cause analysis helped us see that the real need was for inpatient beds.
CHALLENGE
EXECUTIVE SUMMARY
The emergency department (ED) is
Initially focused on redesigning their emergency department (ED), Orange Regional
experiencing daily holds. Currently,
Medical Center (ORMC) engaged Array Advisors to map the current and future state
observation patients are sent to any
process. It became clear that there were some downstream bottlenecks causing the
available bed in the hospital. Staff fears
ED to be overwhelmed with patients.
that this bed assignment paradigm may
The ORMC team was interested in seeing if they could increase ED capacity by adding
be causing the back-up in the ED. Array
holding beds for admitted patients waiting in the ED for an inpatient bed. We used a
looks to provide clarity around the impact
simulation model to test the effect of implementing the future state patient flow.
of improving flow in the ED and cohorting
Holding beds appeared to alleviate the problem, but we did not believe they were
observation patients.
the best use of capital and they clearly did not solve the root cause of the issue.
SOLUTION
We recommended ORMC perform a study of the inpatient and observation patient
Throughput Analysis
We hypothesized that moving observation patients, who were currently being treated
interaction to determine if inpatient bed capacity was the root cause. in inpatient beds, to a cohorted unit would create capacity for admitted inpatients and
After developing a future state work
reduce the number of holds in the ED.
flow focused on separating the very sick patients from the less sick patients in the
Array’s modeler developed a second simulation model to study the utilization and
emergency department (ED), Array worked
bed need of all inpatient units. The model also demonstrated the effect of treating
to determine how a dedicated observation
observation patients in a dedicated unit, rather than inpatient units.
unit would impact current crowding in the
The models provided the ORMC team with visuals, helping them see the impact of
ED.
adding an observation unit. This also helped them determine the best use of their capital dollars.
PROJECT HIGHLIGHTS
2
Simulation Models: 1 ED, 1 inpatient
30
Observation Beds Needed to Reduce ED holding
6
RAZ Positions Added
CLIENT PROFILE Orange Regional Medical Center Middletown, NY
Process Mapping We began our study by mapping out the current state of operations in the ORMC emergency department (ED). As the ORMC team developed the current state map, they gained consensus around how patients were flowing through the department,
Recognized by US News and World
and what some of the biggest barriers to flow were. This allowed them to develop a
Reports as a world class regional provider,
future state patient flow focused on removing current barriers, leading to a better
Orange Regional Medical Center is
patient experience.
committed to excellence in all areas. By
The future state mapping activity resulted in a transformation plan. To attain the
recruiting top physicians and specialists;
metrics specified in this case study, ORMC must completely implement the future
by utilizing the most advanced technology
state, including each of the items in the transformation plan. We developed a discrete
and diagnostic equipment; and by never
event simulation model to help us better understand whether holding beds would
forgetting what the power of compassion
provide enough capacity to reduce the strain from not having an adequate number of
in a healing, patient-centered environment
inpatient beds currently felt by the ED.
means to those they care for. www.ormc.org
Emergency Department Simulation Study The simulation study revealed that the new process, which shifts the traditional triage activities to a rapid assessment zone (RAZ) and incorporates a pivot nurse, could improve door-to-doctor time seen in the current state, if the appropriate resources are allocated. This initial analysis of ED throughput indicated that admitted patients were being held in the ED for extended durations, leading to the perception that the ED did not have enough treatment positions. The simulation results (Figure 1) helped ORMC staff see how different resource quantities affect average door-to-assessment time and the distribution of door-toassessment times over the patient population. Allowing all ORMC team participants to engage with the interactive results helped everyone on the team understand the impact of changing the available quantities of each resource.
TOOL
Staff expected that most of the ED holds were observation patients, but the data showed us that about 3/4 of ED holds were actually inpatients waiting for beds. To further explore how inpatient bed assignments for observation and admitted patients affects ED throughput, Array developed a simulation model focusing on the interactions between the ED and inpatient unit.
Throughput Analysis Orange Regional Medical Center • 06.27.2016
The processing rates of each step combine to create total throughput time. Steps with longer durations that occur later in the process create bottlenecks, and nonvalue-added waiting time will increase the time it takes to get through the system. Array’s experienced team works with you to determine the optimal process-steps configuration that maximizes the value quotient in your system.
Main ED Beds
1
2
3
4
22
22
22
22
RAZ Beds
6
5
6
5
Vertical Beds
10
10
10
10
Holding Beds Door to Assessment (average)
12
12
10
10
6.12
6.55
7.85
8.31
0.00
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
12.00%
Percent Waiting Specified Durations for Door to Assessment
10.00% 8.00% 6.00% 4.00% 2.00%
0.77%
1.22% 0.89% 1.34% #N/A
0.00%
0.99% 0.58% 0.87% 0.71%
10-15 mins
Figure 1: Simulation results decision tool.
Page 2 | Case Study
5
15-20 mins
#N/A
0.50% 0.66% 0.62% 0.77%
20-25 mins
#N/A
0.43% 0.53% 0.55% 0.63%
25-30 mins
#N/A
TRANSFORMATION
Inpatient Simulation Study The inpatient simulation study helped quantify the impact of adding an
Our core mission is the same as that of
observation unit. Most of the ED holds today are admitted patients waiting
our clients: improve the quality of our
for beds in an inpatient unit. Currently, the staff treats observation patients in inpatient beds. Grouping the observation patients into one unit will make capacity available in the inpatient units, leading to less crowding in the ED.
improvement at all levels of our
two surgical floors (2S and 4W). This will alleviate some of the capacity strain
organization. We seek to empower team
currently experienced on the other floors that have tele-monitoring. Figure 2
members to be agents for good change.
shows how much lower the percent utilization is on each of the surgery floors.
Convert to tele for cardiac overflow
Convert to a medical floor with tele
our staff to reach for success. At Array, we are establishing a culture of continuous
Given the studies’ results, we recommended adding telemetry monitoring to the
We begin all endeavors by considering
Unit
% Utilization
% Utilization
2S
35%
27%
(no observation unit)
work, increase our efficiency, and motivate
(with observation unit)
process before exploring solutions. Our team can guide your organization through pre-design, ensuring clear goal-setting;
2S-STELE
66%
45%
3N-CTELE
97%
95%
3E (ICU)
target outcomes; process analysis
79%
70%
3S-CTELE
85%
72%
and design; and decision support. Our
3W (ICU)
82%
79%
Lean-led approach to project definition
3W-M/CTELE
81%
66%
4N
99%
99%
provides a clear path to the right project
4S
95%
93%
4S-MTELE
96%
95%
4W
55%
41%
4W-STELE
78%
72%
5N
97%
97%
5S
91%
89%
5S-MTELE
90%
86%
5W
75%
68%
project, it’s important to understand the
5W-MTELE
48% No observation unit
24% 25 beds 30 beds 35 beds
customer needs, work flow and optimal
OBSERVATION
N/A
69%
58%
before you begin to design.
What can we do to optimize our capital spending? Before beginning design on any capital
49%
future state. Our team can guide your organization through pre-design, ensuring
Figure 2: Results table showing percent utilization with different sized observation units.
clear goal setting, target outcomes, process analysis, process design and
The addition of an observation unit increases available capacity in the inpatient
decision support. Our Lean-led approach
units, reducing the number of patients and frequency of holding in the ED, allowing
to project definition provides a clear path
Array to remove the ED holding beds from the initial solution. The table in Figure
to the right project before you begin to
3 shows the effect on ED door-to-assessment time of adding an observation unit
design.
and removing the proposed holding beds. The final future state recommendation for the ED includes removing the 12
Tools used:
proposed holding beds and adding four additional Main ED beds to keep the
Capacity & Utilization Assessment,
average door to assessment time at the goal of about six minutes. We also
Consensus, Process Mapping, Data
recommend adding an observation unit to increase inpatient bed capacity.
Analysis, Data Visualization, Simulation Modeling
Future State (from ED study)
Future State With OBV Unit
Future State With OBV + Increase Main ED Beds (as drawn)
Main ED Beds RAZ Beds Vertical Beds Holding Beds
22 6 10 12
22 6 10 0
26 6 10 0
Average Door to Assessment Time (min)
6.12 minutes
10.04 minutes
6.70 minutes
Observation Beds
0
30
30
Figure 3: Results table showing how ED door to assessment time is affected by the addition of 30 observation beds. Cast Study | 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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We are Array Advisors, your trusted partners in Strategy Development, Organizational
individuals lead our efforts, which focus on your unique place in the healthcare delivery spectrum. Our knowledgeable staff can help you solve strategic business problems and develop a method to improve efficiency and utilization.
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: APRIL 2017