Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast

1. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month September 24th Access & Patient Flow Panel Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html

2. Hopefully you provided your name & organization when you signed in. If so: Just say Hi in the Chat Pod and we’ll capture your name and organization in the log. If not: identify yourself and organization in the Chat Pod to the left of your screen. If there are more than one attending on your sign-in, tell us how many by saying “Hi (tell us the number of attendees) “ Register your Attendance

3. Rural / Outstate ? Metropolitan area ? Organization that has (or serves) both ? Poll: Who is Attending this Session ?

4. Healthcare system Hospital Clinic or Clinic System Long term care Healthplan Homecare / Hospice A Quality Support Organization Other ? (Identify other in Chat Pod) Poll: Who is attending: Organization Type ?

5. 1 2 3 4 5 6 7 >7 Poll: How many total participating in your room ?

6. I am a healthcare quality professional and am interested in additional education. I am a healthcare professional interested in developing quality skills as a core competency. I am a healthcare professional interested in learning more about healthcare quality. Poll: What do you hope to gain by participating?

7. A.   What innovative changes have you made that improved patient access and/or patient flow in your:                 -  clinic ?                 -  Emergency Dept ?                 -  hospital ?                 -  long-term care facility ? B.  What do you consider to be your key measures of throughput/flow in your:                 -  clinic ?                 -  Emergency Dept ?                 -  hospital ?                 -  long-term care facility ? C.  Have you tied "Lean"  to your access and flow ?                If so,  in what way(s) ? D.  What issue/problem have you not been able to solve and would like suggestions from the audience. Questions posed to the Panel

8. Quality Resource Specialist Lake Region Healthcare Corporation 712 S. Cascade Street Fergus Falls, MN  56537-1234 218-736-8068    Fax: 218-736-8757 BaHydukovich@lrhc.org Panel Member: Betty Hydukovich RN

9. Project Goals: 1. Reduce or mitigate patient wait time 2. Enhance communication to patient and family 3. Improve patient satisfaction ●Project Measures 1. Patient wait times (measures access and throughput) 2. Patient Satisfaction scores The Emergency Department Patient Experience

10. Assigned a “resource nurse” each shift Re-defined roles for procedure nurses and unit clerk Installed additional computers in patient rooms Two additional work stations for nurses/doctors Improved tracker board functioning Dedicated “fast track” rooms on weekends when there are 2 ED physicians What innovative changes have you made that improved patient access and/or patient flow ?

11. Decreased Wait Times ◦ From lobby / triage to room ◦ From room time to time seen by ED MD ◦ From time seen by ED MD to time seen by hospitalist ◦ Disposition time – out the door What do you consider to be your key measures of throughput/flow

12. Rapid changes put into effect (Kaizen events) Banish waste (reduced patient wait times, standardized staff roles, limited unnecessary movement, cut out repetitive documentation, etc.) Implemented employee ideas to utilize talents and skills to their fullest Have you tied "Lean"  to your access and flow? If so,  in what way(s) ?

13. ANY suggestions would be helpful ◦ concerned about “sustaining the gain” Thank you for allowing me to share this project with you! Betty Hydukovich RN – Quality Resource Specialist Lake Region Healthcare Corporation, Fergus Falls What issue/problem have you not been able to solve and would like suggestions from the audience?

14. St. John’s ED Lean Flow Project Brownbag Panel September 24th, 2009 Corin Hammitt HealthEast Process Improvement Consultant 651-232-0327 cehammitt@healtheast.org

15. Agenda St. John’s ED Patient Throughput Batching and Long ALOS Triage & Rooming Patients Rapid Treatment Design

16. St. John’s ED • Annual Volume = 38,000 • 25 beds • 20 beds for all acuity levels • 1 trauma room • 3 resuscitation rooms • 5 bays for low acuity patients (4’s and 5’s only) • 23% of ED patients are admitted • ~50% of St. John’s Inpatients come through the ED

17. Patient Throughput

18. The Situation: St. John’s ED Emergency Room Capacity SITUATION: The ED is full, LWBS = 4%, patient complaints are pouring in. We have to start ‘rounding’ on the waiting room patients to ensure them that they will be seen soon. Admission Process (Patient Flow out of ED)

19. Conventional Solution Emergency Room Capacity SOLUTION: Expand the ED. Currently have 25 beds Expand to 36 beds Meet the needs of the community. Right? Admission Process (Patient Flow out of ED)

20. Lean Flow Solution • Focus on the outflow of patients • In our case, the ED patient admission process • Don’t make the funnel larger- move patients out to bring new patients in • If a patient spends 30 fewer minutes in the ED and moves up to the unit, that releases capacity in the ED • No investment in expansion, staff, or physicians!

21. ED Admit Process: Pre-Lean Flow • Data: • 10-12 Handoffs • 9 roles involved, plus Ops Center • 4 Handoffs prior to making bed request = 20 minute delay! • Total Cycle Time = 70 minutes (avg) • Issues: • Patients waiting to be admitted to inpatient unit take up ED bed capacity- over 16 hours each day of unnecessary bed occupation • Impact: • ALOS for admitted patients = 4.8 hours in the ED • LWBS = 4%

22. ED Admit Process: Post-Lean Flow • Data: • 3 Handoffs ; ACT RN is coordinator of the admission • 4 Roles Involved, plus the Ops Center • New Cycle Time = 30 minutes (avg) • Impact: • ALOS for admitted patients now 4.05 hours (as of Aug. 28, 2009) • August LWBS = 1.85% • 16 hours of ED capacity released each day • Opportunity to increase daily patient throughput and revenue

23. Batching and Long ALOS

24. Sources of Long ALOS ALOS < 250 min ALOS ≥ 250 min • Shift Change impact on Door to Bed and ALOS: • 1-2 hours prior to shift change (evenings and nights) Door to Bed is significantly longer • Long ALOS attributable to Shift Change (for those arrivals occurring at or 1-2 hours before shift change) • After further investigation, we found out that the provider shifts were set up in a way that inhibited handing off patients, thus providers would refrain from seeing new patients 2+ hours prior to end of shift. • Solution: • Change provider shift structure to promote hand off of patients between providers • Eliminate the batching of patients at shift change

25. Triage & Rooming Patients

26. Bottleneck Q: Wait for ED Bed Triage (1 Server) Patient is Roomed (22 servers) Cycle Times:

27. Triage (1 Server) Q: Wait for ED Bed Patient is Roomed (22 servers) Triage (1 Server) Pull to Full Cycle Times:

28. Pull to Full Pull to Full: Arrival to Patient Roomed • Pull to Full Eliminates Patient Waiting Waste • Empower the Triage RN to room the patient immediately if there are open rooms • Don’t wait for chart to go back to Charge RN • Eliminate the decision-making by only one person (gate-keeper) • If only one room is open, Triage RN will consult with Charge RN

29. Rapid Treatment Design

30. Before 4/19/09 Rapid Treatment Area (T1-T5) Rapid Tx Rapid Tx Computer/ Workstation Rapid Tx Rapid Tx Rapid Tx

31. Room Utilization of Rapid Tx • Rapid Treatment Area Overall Room Utilization = 34% • The rooms were not used to their full potential • Layout and motion waste meant that the rooms were not used equally

32. After 7/1/09 Rapid Treatment Area (T1-T5) Rapid Tx Rapid Tx Rapid Tx Rapid Tx Computer/Workstation Rapid Tx Rapid Treatment Waiting Lounge

33. Measures

34. St. John’s ED Dashboard Dashboard-Most data is available through electronic tracking board This analysis is done monthly & posted in ED break room area The ED Clinical Manager is trained on how to perform this analysis

35. Measures- Details Arrivals, Admits and LWBS by Day of Week ALOS Distribution < 3 hours 3 -4 hours 4-5 hours > 5 hours

36. Measures- Details ED Arrivals and LWBS by Hour of Day Door to Bed (min.) by Hour of Day

37. Summary

38. Critical Success Factors Go to Gemba! Measurement Transparency Frontline participation Open-mindedness Remove the barriers to solutions Respect for one another Don’t expect perfection

39. Questions ?

40. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month October 22nd Patient Safety Innovations Panel Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html