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Improving Emergency Room Efficiency & Service

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Improving Emergency Room Efficiency & Service Improving Emergency Room Efficiency & Service Presentation Transcript

  • Improve the Efficiency and Service of the Emergency Room at North Side Hospital John Melton, VP and CEO Washington County Operations meltonjw@msha.com Kerry Vermillion, CFO Washington County Operations vermillionkw@msha.com 1
  • Mission Statement Improve the ED process at North Side Hospital to: – Decrease the LOS to < 100 minutes – Improve Patient Satisfaction to > 75%tile – Reduce LWBS to < 1% Project will begin on July 1, 2004 and will be completed November 30, 2004. 2
  • Team Members John Melton SVP & CEO, Washington County Operations Kerry Vermillion VP & CFO, Washington County Operations Melanie Stanton, RN Assistant Administrator NSH David Merrifield, MD Emergency Medicine Tommy Sparks Director, Emergency Department Shonna Lane ED Stacie Mashburn RN Med/surg JoAnn Winters Environmental Services Heather Hambrick, RN ICU Sarah Goad Patient Registration Tamera Fields Director of Performance Improvement Rachael Holland Radiology Tech Karen Lones, RN ED Case Management Janice Gentry, RN Lab Jim Murray Director of Management Engineering 3
  • Diagnosis Flow chart of the current process Fishbone Diagrams Data review and analysis Press Ganey Length of Stay Left Without Being Seen (LWBS) Visits by time of day 4
  • Process Flow Chart (original) Physician enters patient room and Flow chart Legend Patient Enters treats patient NSH ED Clerk registers Start/End patient Action Physician enters any Patient meds on chart and Patient Returns to completes writes prescription waiting room Decisio n complaint form Flow Direction Patient hands Nurse calls patient Physician places complaint form to from waiting room chart at nursing Registration clerk station Nurse places patient Yes in ED room Is Patient Nurse gives meds Registration Clerk calls for Nurse Emergent? from PYXIS No Nurse w rites his/her name on a board for patient and family to see. ED Nurse does YES JCMC Clerk asks patient Instructs patient to gow n immediate Nursing calls to sit in waiting and connects any Will Patient be W here will Patient assessment monitoring equipment. JCMC Bed room admitted? be admitted? Also completes the Placement Triage Sheet in the chart. NO Clerk puts complaint form in triage w indow and NSH starts patient chart Nurse places chart in physicians box Nurse educates Nursing calls EMS Triage Nurse patient on home Services for retrieves complaint care, takes Nursing contacts Transport of patient Physician evaluates form and chart discharge vitals, and appropriate unit nurses comments on Triage Sheet completes discharge paperwork Triage nurse calls patient from waiting ED Nurse gives Physician enters room report to floor patient room nurse Patient dresses and Nurse Triages patient and prepares to leave completes assessment Physician assesses form and places on chart patient Physician orders any Nurse asks patient to Is Patient Registration clerk tests or exams YES return to w aiting room deemed necessary Self-pay or takes information Co-pay? and/or money from patient Registration Clerk Physician places orders on chart and chart at calls patient to Patient is nursing station NO registration desk discharged from ED 5
  • Fishbone Diagram – LOS 6
  • Fishbone Diagram – LWBS 7
  • Fishbone Diagram – Patient Satisfaction 8
  • List of Customers Johnson City / Washington County, Tennessee Community Emergency Patient Patient’s family Emergency Department Nurses and Physicians Ancillary areas Acute care nursing Area EMS Units Tertiary Care Center Nursing Homes and Assisted Living facilities Payers 9
  • Data Review and Analysis Press Ganey Survey Manually collected LOS and LWBS data Staff Interviews – physician and nursing Observation 10
  • Manual Data Entry N o rth S id e M o n th ly E D S ta tis tic s M o n th : J u ly 2 0 0 4 M a in E D V is its = T o ta l V is its = In p a tie n ts = O u tp a tie n ts = D o o r to D o o r to D o o r to JC M C O th e r ER D a te LW BS AM A ALO S (T o ta l R e g is tra tio n s ) (T o ta l R e g . - L W B S ) (# N S H A d m its ) (T o ta l V is its - In p a tie n ts ) T ria g e Room ER M D A d m its A d m its H o ld 1 63 1 62 1 61 0 13 43 67 124 2 0 0 2 69 0 69 2 67 0 6 35 49 119 1 0 0 3 66 0 66 1 65 0 10 31 35 106 2 0 0 4 82 0 82 1 81 0 9 33 52 114 0 0 0 5 90 0 90 2 88 0 23 49 57 144 2 1 0 6 92 0 92 4 88 0 10 46 61 142 0 1 0 7 64 0 64 3 61 0 12 35 50 125 3 0 0 8 57 3 54 2 52 0 15 42 82 235 2 0 0 9 65 2 63 2 61 0 6 38 56 158 1 0 0 10 54 0 54 3 51 0 12 42 72 203 3 0 0 11 70 3 67 1 66 0 6 35 113 117 2 0 0 12 63 0 63 1 62 0 8 39 47 110 1 1 0 13 81 0 81 5 76 0 20 59 97 179 0 3 3 14 67 0 67 3 64 1 7 30 47 126 0 0 0 15 68 2 66 2 64 0 8 41 108 146 1 0 0 16 67 2 65 1 64 1 8 33 55 116 0 0 0 17 68 0 68 2 66 0 12 33 52 113 0 0 0 18 69 0 69 3 66 0 11 45 64 170 4 0 0 19 82 3 79 7 72 0 11 48 63 190 1 1 0 20 55 1 54 1 53 0 7 32 46 138 2 1 0 21 69 2 67 3 64 0 16 36 58 123 1 1 0 22 55 2 53 2 51 0 4 27 86 138 2 0 0 23 64 2 62 5 57 0 9 37 61 136 0 0 0 24 65 0 65 1 64 0 10 31 51 100 1 0 0 25 80 1 79 2 77 0 8 33 112 0 0 0 26 73 1 72 3 69 1 11 37 50 116 0 0 0 27 64 0 64 0 64 0 8 45 63 117 0 0 0 28 66 0 66 2 64 0 8 44 58 113 1 0 0 29 80 2 78 8 70 0 9 34 71 135 0 0 0 30 52 0 52 5 47 0 6 27 92 0 0 0 31 56 0 56 1 55 0 9 29 50 99 0 0 0 1 .3 % SUM 2116 27 2089 79 2010 3 312 1169 1821 4156 32 9 3 AVG 68 1 67 3 65 0 10 38 63 134 1 0 0 11
  • Press Ganey Tool 12
  • Intervention Institutional leadership change (6/04) Quick “Reg” (10/04) Purchased additional equipment (10/04) Cabinets for ED rooms Vital Works ED tracking system IV Pumps Improved Lab service availability on-site (7/04) 13
  • Intervention (cont’d) Removed “Saratoga” Satisfaction Tool (7/04) Improved relationships with physician leadership (6/04) Implemented Bedside Registration (10/04) Increased Radiologist coverage (Productivity Spin off) (9/04) Enhanced Lab Service and Courier service (8/04) Implemented Bedside Discharge process(10/04) Orchestrated Psych Pickup by Indian Path Pavilion (another MSHA facility) (6/04) 14
  • Intervention (cont’d) Created attitude shift about accepting patients diverted from JCMC (6/04) Designated patient and family parking for the ED (6/04) Enhanced ED Room Appearance (8/04) Placed TV’s and phones in rooms (8/04) Eliminated hand written complaint form (10/04) Improved work relationship with EMS crews (in biker bar) (Ongoing) 15
  • JU L 1,400 1,500 1,600 1,700 1,800 1,900 2,000 2,100 2,200 2,300 2,400 FY 0 A 3 U G S EP O C T N O V D EC JA N FE B M A R A PR M A Y JU J L UN FY 0 A 4 U G S ED Visits EP O Impact C T N O V D EC JA N FE B M A R A PR M A Y JU JU L N FY 0 A 5 U S G Project initiated EP T 16
  • JU L 0 10 20 30 40 50 60 70 80 90 100 FY 03 AU G SE P O C T N O V D EC JA N FE B M AR AP R M AY JU JU L N FY 04 AU G SE P O C T N Impact O V D EC Acute Admissions JA N FE B M AR AP R M AY JU JU L N FY 05 AU G Project SE initiated P 17
  • 7/ 1/ 7/ 2 00 0 50 100 150 200 250 300 15 3 / 7/ 200 29 3 / 8/ 200 12 3 / 8/ 200 26 3 /2 0 9/ 03 9/ 9/ 2 00 23 3 / 10 200 /7 3 10 / 20 /2 03 1/ 11 200 /4 3 11 / 20 /1 03 8/ 12 200 /2 3 12 / 20 /1 03 6 12 /20 /3 03 0/ 1/ 200 13 3 / 1/ 200 27 4 / 2/ 200 10 4 / 2/ 200 24 4 /2 3/ 004 9/ 3/ 2 00 23 4 /2 Impact Baseline and Project 4/ 004 6/ 4/ 2 00 20 4 /2 5/ 004 4/ 5/ 2 00 18 4 /2 6/ 004 1/ 6/ 2 00 North Side ED Length of Stay 15 4 / 6/ 200 29 4 / 7/ 200 13 4 / 7/ 200 27 4 / 8/ 200 10 4 / 8/ 200 24 4 /2 9/ 004 7/ FY0 5 FY0 5 9/ 2 00 21 4 / LCL b as eline UCL b as eline 10 200 Bas eline FY0 4 Bas eline FY0 4 /5 4 /2 00 4 18
  • 7/ 1/ 20 0 50 100 150 200 250 04 7/ 8/ 20 04 7/ 15 /2 00 4 7/ 22 /2 00 4 Removed Saratoga 7/ 29 /2 00 4 8/ 5/ 20 04 8/ Lab Improvements 12 /2 00 4 8/ 19 /2 00 4 8/ 26 Impact /2 00 4 9/ 2/ 20 04 9/ 9/ 20 NSH ED FY05 Length of Stay 04 9/ 16 /2 00 4 Radiology Improvements 9/ 23 /2 00 4 9/ 30 /2 00 4 FY05 LOS 19
  • 0.00% 0.20% 0.40% 0.60% 0.80% 1.00% 1.20% 1.40% 1.60% 1.80% 2.00% Ju l- 0 Au 3 g- 0 Se 3 p- 03 O ct -0 N 3 ov -0 D 3 ec -0 Ja 3 n- 0 Fe 4 b- 0 M 4 ar -0 Impact Ap 4 LWBS NSH ED r-0 M 4 ay -0 Ju 4 n- 04 Ju l- 0 Au 4 g- 0 Project initiated Se 4 p- 04 20
  • Impact Patient Enters NSH ED Redesigned ED Process Flow Patient approaches front desk Clerk "Quick Reg's" patient No RN triages Patient IS ED room av ailable? and orders approved tests Yes Clerk registers patient Clerk calls Patient waits in PCP/LPN/RN to take lobby until room Patient to Room is available RN triages Patient and orders approved tests Physician Treats Patient Re gis tration - Be ds ide -Re gis te rs patie nt Registration collects copay in ED room Patie nt is Dis char ge d 21
  • Press Ganey Actual Scores Project initiated 84 84.3 83 82 82.3 80 79.6 79.8 78.7 78.8 78 76.5 76 76.3 74 74.1 72.7 72 70 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 FY 02 FY 02 FY 03 FY 03 FY 03 FY 03 FY 04 FY 04 FY 04 FY 04 FY 05 Quarter 22
  • Press Ganey Percentile Scores Project initiated 70 65 60 56 50 44 40 30 28 27 20 19 21 21 18 10 6 7 0 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 FY 02 FY 02 FY 03 FY 03 FY 03 FY 03 FY 04 FY 04 FY 04 FY 04 FY 05 Quarter 23
  • Hold The Gains 24
  • Hold The Gains A B B C B C C A 25
  • Future Action Items Fully Implement Bedside Registration Maximum Utilization of Vital Works Elimination of manual data tracking Graphical representation of data trends Construction and Renovation of Entrance Upgrade monitoring equipment Fully Integrate Clinical Documentation System into NSH ED Full time ED Case Manager Improve ED entrance 26
  • Summary of Results to Date • Length of stay declining and headed towards <100 minute LOS goal • LWBS below targeted goal of 1% • Press Ganey Score at 65th %tile, highest %tile ranking since PG instituted (Goal >75th %tile) 27