Emergency rooms in the United States aren’t known for their efficiency. Data from the Centers for Disease Control and Prevention (CDC) shows that the 110 million people who visited an emergency room in 2004 spent an average of 3.3 hours from check-in to physician visit to discharge.
American emergency rooms are not just inefficient, they are facing a crisis. Most ER visits are made by the elderly or the uninsured at a time when the number of hospital emergency departments has been cut by 14 percent. Other CDC statistics show that ER visits by adults aged 22 to 49 increased 19 percent while visits by Americans aged 50 to 64 grew 15 percent.
Peggy Fountain, director of the emergency department at Meadows Regional Medical Center in Vidalia, Ga., is all too familiar with these issues. At one point, the average length of stay for her emergency department patients soared to more than 200 minutes, well below the national average, but still unacceptable to Meadows’ management.
“We had issues with bottlenecking, turnaround times, decreased satisfaction and overworked nurses,” she recalled. “One day, our president and CEO, Alan Kent, asked if I would be interested in having Georgia Tech assist us. Working here 24/7, there may be things that need to be changed that I can’t see but an outsider could.”
With funding from the Georgia Rural Economic Development Center (GREDC) at East Georgia College in Swainsboro, lean specialists with Georgia Tech’s Enterprise Innovation Institute conducted a three-day lean overview workshop and value stream mapping event with Meadows’ emergency department in June 2005. In addition to Fountain and Kent, workshop participants included the ER nursing staff, an ER physician, the radiology director, laboratory manager and business office staff.
“You shouldn’t ask your employees to do something you’re not willing to do yourself. How will you know where to deploy resources if you don’t learn about the opportunities themselves?” asked Kent. “The engagement of senior management is critical to any significant organizational change.”
Frank Mewborn, the Georgia Tech lean specialist who led the events at Meadows, agrees with Kent’s assessment. “It is important to involve top management as well as those who are in the trenches every day,” he noted. “The first day of training we had about 20 people across all departments, and about 12 participated when we actually did the value stream mapping.”
The lean team at Meadows developed 44 action items for reducing lead time to admit, treat and discharge a non-critical ER patient, 18 of which were determined to be low-cost and high-impact. The ideas fell into one of seven categories: 5S and visual controls, cross-training, equipment, hospital procedures, patient information, general procedures and staffing. 5S — which stands for sort, straighten, shine, systemize and sustain is a philosophy and a way of organizing and managing the workspace so morale and efficiency are increased.
“Our Pyxis system — which is an automated mobile supply station that we pull supplies from based on a patient’s name — were all set up differently,” Fountain said. “Now they are all standardized so they contain the same general supplies in the same place, and that has helped nursing a lot.”
Other changes that were made included labeling racks, trays and drawers; installing a color-coded flag system outside patient rooms; issuing patients red allergy armbands to alert medical staff; and adding a holding area for patients who need to see a doctor but don’t need a room. Fountain also touts the implementation of the T System , a software program specifically designed for the emergency department that is able to interface with other software systems used throughout the hospital.
Integrated with the T System is a large, plasma screen monitor in the nurses’ station that can show staff who is in the waiting room, who needs an X-ray and who can be put into a room or a wheelchair. The T System also documents length of stay, lab tests ordered, physician and nurse assigned to the patient and discharge disposition, as well as patient name, room number and prior ER visits, if applicable.
Meadows has also created incentives for its emergency department staff for meeting the stated goal of 110 minutes length of stay. Timers set to 30-minute increments are activated once patients come in the door, and a team of nurses assist with getting IVs started, providing respiratory assistance or monitoring them with an EKG. Already, the emergency department staff has met that goal on numerous occasions.
“After the value stream mapping exercise, we had about 75 sticky notes posted on a wall that signified different changes that needed to be made,” Kent remembered. “As those ideas were implemented, the staff would cross them off and move them to another wall. Over a period of months, I saw those 75 notes drop to about 20. About half of the items in there were low or no cost.”
As a result of the lean health care implementation, Meadows has realized outstanding results. Physicians, on average, are seeing more patients per hour than before the lean implementation. In 2005, average length of stay per patient was 247 minutes; thus far in 2007, it is 139 minutes — an astounding 43.7 percent reduction. That success is reflected in patient satisfaction numbers as well: approximately 92 percent of patients reported that “Overall, I am pleased with the quality of care provided at this facility.”
“We’ve grown our business overall by 10 percent while reducing our turnaround time, which in an emergency room relates almost directly to patient satisfaction and willingness to come back as a repeat client,” noted Kent, a 1979 health systems graduate of Georgia Tech. “It also has improved work life for participants so turnover is lower. We ended up with some good cross-training opportunities and more of a team environment in the ER now.”
Fountain also points out that emergency room staff is more empowered to take initiative and make changes that could positively impact their work process.
“Staff members realize that it’s not just the ER’s problem it’s everyone’s problem. Whatever we can do to improve the process makes everyone’s job easier,” she said. “Walking into this ER is stressful enough you don’t need to walk in stressed out about the process part of it, in addition to what you’re going to see that day.”
Meadows’ management plans on utilizing lean health care principles when it builds a new, state-of-the-art hospital. The original facility, built in 1963, employs 600 people and operates 87 beds as well as a 35-bed nursing home, an eight-bed outpatient facility, and one part-time and two full-time operating rooms.
“We want to design the new facility using lean processes before architects draw up the building,” said Kent, who also plans to incorporate online patient registration, self check-in kiosks and bar-coding into the new hospital. “We’ll draw a building around the parameters of the number of ER visits, OR visits, square footage needed, beds needed, budget, et cetera. We want to optimize process before we draw the first line. We want form to follow function.”
Jack Bareford, GREDC director, believes Meadows’ success can be replicated in other rural Georgia hospitals. GREDC focuses on economic development issues that build economic strength and develops innovative, practical strategies that prepare rural communities to prosper.
“Rural health care is one of the most important issues in successful economic development, and communities that have access to good health care can survive and grow,” Bareford said. “With the many challenges there are to rural hospitals, such as care for the uninsured, reliance on lower-paying publicly-funded insurance plans, skyrocketing liability costs and shortages of health care professionals, the lean health care model can save time and resources to help hospitals remain healthy.”
Kent agrees that Meadows’ approach could be successful in other hospitals, but notes that change is often difficult, especially in health care.
“In health care, we live in these little silos. People should be hovering over us asking how we implemented lean. Success in the past does not necessarily ensure success in the future. If you don’t change and innovate, it will kill you,” Kent noted. “One of the goals of lean health care is to awaken a new level of thinking and introduce manufacturing approaches that have been proven to produce excellent efficiency and profitability.”
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Writer: Nancy Fullbright