U.S. emergency departments serve as the front door for more than half of all hospital admissions, resulting in long wait times, crowded conditions, and highly variable care and outcomes. In 2008, the average length of stay in U.S. emergency departments was four hours and three minutes. In Georgia, the statistics were slightly worse, ranking 34th out of the 50 states with an average wait time of four hours and 20 minutes.
The emergency department (ED) at Piedmont Fayette Hospital, a 143-bed facility located 30 miles south of Atlanta, was not immune to any of these modern health care challenges. According to Dr. Richard Mitchell, lean champion for Piedmont Fayette and subsequent chief medical officer, the average length of stay for patients that were treated and sent home was more than four and a half hours, as many as eight percent of patients were leaving without being seen and patient satisfaction scores were in the single digits.
“There was a lot of turmoil when we started,” he recalled. “Piedmont Hospital already had a contract with Georgia Tech to conduct lean projects to analyze and streamline flow processes, and Piedmont Fayette’s executive staff wanted us to look at processes in the emergency department.”
In July 2008, Jennifer Trapp-Lingenfelter of Georgia Tech’s Enterprise Innovation Institute helped train Piedmont Fayette staff in lean principles, an operational strategy that focuses on eliminating waste while increasing value-added work. Lean techniques improve profitability, customer satisfaction, throughput time and employee morale. The project began with a value stream map, a diagram used to analyze the flow of materials and information required to bring a product or service to a consumer.
“With detailed review of patient flow through ED, the first thing we realized was that the department was physically set up backwards. The sickest patients were being taken all the way through the department to the back of the ED and being placed in smaller rooms while the least sick patients were being seen right in front of the ED right off the ambulance entrance in an area that had previously been the hospital’s intensive care unit,” noted Trapp-Lingenfelter. “So the larger, more equipped rooms were being used for the lower acuity patients.”
To address this situation, the team re-assigned rooms and nursing stations so that the sickest patients are now placed in the large rooms at the entrance of the emergency department. The charge nurse was relocated from the front nursing station to be able to better manage incoming patients from the ambulance and reception areas.
In addition to changing the layout, separate patient flow teams were established for sickest, moderate and least sick patients. The least sick patients now go into an “express track,” where they can be examined by a physician assistant. Physicians are assigned to either the moderate or sickest track, and patients move through the system more smoothly and quickly.
“Before if we had two doctors and each took a very sick patient, the moderately-ill patients were waiting for more than two hours to be seen,” Mitchell said. “The basic idea was to keep that highway open for those moderate patients, so that when the ED starts getting clogged up with sicker patients, you can see them.”
As a result of these changes, the time in department for discharged patients dropped from four and a half hours to three hours and 45 minutes, a savings of 45 minutes per patient (32,850 hours annually) in spite of the hospital’s rising patient volumes. The percentage of patients leaving without being seen dropped from six percent to three percent, and patient satisfaction scores soared from the single digits to 64 percent.
The team also conducted a number of projects in 5S, a method for organizing the workplace. Often-used supplies had been stored in a room at the periphery of the department, were not labeled and were difficult to locate. After implementing 5S (sorting, straightening, sweeping, standardizing, and sustaining), supplies were moved to a central area and were color-coded and labeled in user-friendly language.
“Before the 5S project, supplies had been labeled in a totally incomprehensible way so no one could find anything in the supply room,” Mitchell said. “When we turned the nurses loose and let them sort stuff, they probably got rid of 40 percent of the supplies we had. By asking them how to set up the ED, they were being listened to and empowered.”
Tammy Estrada, director of emergency services, agrees that having front-line staff involved made all the difference in implementing the lean projects.
“We are constantly doing lean every week,” she observed. “We’ve been able to build on the projects that these guys did – the techniques and the principles – and now it’s a part of our language and a part of our culture.”
Mitchell acknowledges that the biggest challenge of the project was sustaining the changes and not getting frustrated when significant changes in the hospital’s metrics weren’t readily apparent.
“We had perfectly good changes, and they were the right changes, but we had difficulty sustaining them. What we were missing was the intense follow-up and the involvement of hospital leadership,” he recalled.
For three months, executive staff and emergency department leadership held nightly telephone conference calls to discuss what had happened each day and to reinforce management’s commitment to the project. According to Lisa Hedenstrom, vice president for patient care services and chief nursing officer for Piedmont Fayette, this is when the team started seeing quantifiable changes. They now hold bi-weekly update meetings.
“If you believe in shared governance and giving employees control over their work environment and decisions that they can make then this is a natural thing to do because it allows the people who are doing the work to have input into how the process works in a very systematic way where everyone is valued and appreciated,” she said. “It’s really given us a much better culture to promote patient care, thinking of how we can do things differently.”
In addition to implementing lean in the emergency department, the Piedmont Fayette team also examined a number of processes elsewhere in the hospital: post-surgery discharge, wheelchair access, supply cart storage, radiology test orders, IV pump cleaning, outpatient CT scans, pre-op patient paperwork and women’s services. As a result of these efforts, the time to process admit orders has dropped from 120 to 60 minutes, time spent searching for supply cart items has been cut in half, and turnaround time to clean IV pumps went from 24 hours to mere minutes. In addition, the number of misdirected radiology orders decreased from 15 to less than two per day, and 21 percent more outpatients can be seen with the same number of staff.
Through its Healthcare Performance Group, Georgia Tech project leaders work with healthcare professionals to conduct lean assessments, teach basic lean concepts, develop value stream maps to analyze the flow of materials and information, create quality systems and implement rapid process improvement projects.
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Writer: Nancy Fullbright