Improving Emergency Room Efficiency & Service

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Improving Emergency Room Efficiency & Service

  1. 1. 1 Improve the Efficiency and ServiceImprove the Efficiency and Service of the Emergency Room at Northof the Emergency Room at North Side HospitalSide Hospital John Melton, VP and CEO WashingtonJohn Melton, VP and CEO Washington County OperationsCounty Operations meltonjw@msha.commeltonjw@msha.com Kerry Vermillion, CFO Washington CountyKerry Vermillion, CFO Washington County OperationsOperations vermillionkwvermillionkw@@mshamsha.com.com
  2. 2. 2 Mission StatementMission Statement Improve the ED process at North Side Hospital to:Improve the ED process at North Side Hospital to: –– Decrease the LOS to < 100 minutesDecrease the LOS to < 100 minutes –– Improve Patient Satisfaction to > 75%tileImprove Patient Satisfaction to > 75%tile –– Reduce LWBS to < 1%Reduce LWBS to < 1% Project will begin on July 1, 2004 and will beProject will begin on July 1, 2004 and will be completed November 30, 2004.completed November 30, 2004.
  3. 3. 3 John MeltonJohn Melton SVP & CEO, Washington County OperationsSVP & CEO, Washington County Operations Kerry VermillionKerry Vermillion VP & CFO, Washington County OperationsVP & CFO, Washington County Operations Melanie Stanton, RNMelanie Stanton, RN Assistant Administrator NSHAssistant Administrator NSH David Merrifield, MDDavid Merrifield, MD Emergency MedicineEmergency Medicine Tommy SparksTommy Sparks Director, Emergency DepartmentDirector, Emergency Department Shonna LaneShonna Lane EDED Stacie MashburnStacie Mashburn RN Med/RN Med/surgsurg JoAnn WintersJoAnn Winters Environmental ServicesEnvironmental Services Heather Hambrick, RNHeather Hambrick, RN ICUICU Sarah GoadSarah Goad Patient RegistrationPatient Registration Tamera FieldsTamera Fields Director of Performance ImprovementDirector of Performance Improvement Rachael HollandRachael Holland Radiology TechRadiology Tech Karen Lones, RNKaren Lones, RN ED Case ManagementED Case Management Janice Gentry, RNJanice Gentry, RN LabLab Jim MurrayJim Murray Director of Management EngineeringDirector of Management Engineering Team MembersTeam Members
  4. 4. 4 DiagnosisDiagnosis Flow chart of the current processFlow chart of the current process Fishbone DiagramsFishbone Diagrams Data review and analysisData review and analysis Press GaneyPress Ganey Length of StayLength of Stay Left Without Being Seen (LWBS)Left Without Being Seen (LWBS) Visits by time of dayVisits by time of day
  5. 5. 5 Process Flow ChartProcess Flow Chart (original)(original) Patient Enters NSH ED Patient hands complaint form to Registration clerk Clerk puts complaint form in triage w indow and starts patient chart Yes Is Patient Emergent? Triage Nurse retrieves complaint form and chart Triage nurse calls patient from waiting room Nurse Triages patient and completes assessment form and places on chart Flow chart Legend Start/End Action Decisio n Flow Direction Patient completes complaint form Registration Clerk calls for Nurse No ED Nurse does immediate assessment Clerk asks patient to sit in waiting room Registration Clerk calls patient to registration desk Clerk registers patient Patient Returns to waiting room Nurse calls patient from waiting room Nurse asks patient to return to w aiting room Nurse places patient in ED room Nurse w rites his/her name on a board for patient and family to see. Instructs patient to gow n and connects any monitoring equipment. Also completes the Triage Sheet in the chart. Nurse places chart in physicians box Physician evaluates nurses comments on Triage Sheet Physician enters patient room Physician assesses patient Physician orders any tests or exams deemed necessary Physician places orders on chart and chart at nursing station Physician enters patient room and treats patient Physician enters any meds on chart and writes prescription Physician places chart at nursing station Nurse gives meds from PYXIS Nurse educates patient on home care, takes discharge vitals, and completes discharge paperwork Will Patient be admitted? YES NO Patient dresses and prepares to leave Is Patient Self-pay or Co-pay? YES NO Registration clerk takes information and/or money from patient Nursing contacts appropriate unit JCMC Where will Patient be admitted? NSH Nursing calls JCMC Bed Placement Nursing calls EMS Services for Transport of patient ED Nurse gives report to floor nurse Patient is discharged from ED
  6. 6. 6 Fishbone DiagramFishbone Diagram –– LOSLOS
  7. 7. 7 Fishbone DiagramFishbone Diagram –– LWBSLWBS
  8. 8. 8 Fishbone DiagramFishbone Diagram –– PatientPatient SatisfactionSatisfaction
  9. 9. 9 List of CustomersList of Customers Johnson City / Washington County, Tennessee CommunityJohnson City / Washington County, Tennessee Community Emergency PatientEmergency Patient Patient’s familyPatient’s family Emergency Department Nurses and PhysiciansEmergency Department Nurses and Physicians Ancillary areasAncillary areas Acute care nursingAcute care nursing Area EMS UnitsArea EMS Units Tertiary Care CenterTertiary Care Center Nursing Homes and Assisted Living facilitiesNursing Homes and Assisted Living facilities PayersPayers
  10. 10. 10 Data Review and AnalysisData Review and Analysis Press Ganey SurveyPress Ganey Survey Manually collected LOS and LWBS dataManually collected LOS and LWBS data Staff InterviewsStaff Interviews –– physician and nursingphysician and nursing ObservationObservation
  11. 11. 11 N o rth S ide M onth ly E D S tatistics M o n th : Ju ly 2004 D ate M ain E D V isits = (T otal R egistrations) LW B S To tal V isits = (T o tal R eg . - L W B S ) Inp atients = (# N S H A dm its) O utp atien ts = (T otal V isits - Inpatients) AM A D o o r to Triage D oo r to R oo m D o o r to E R M D ALO S JC M C Ad m its O th er Ad m its E R 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% S U M 2116 27 2089 79 2010 3 312 1169 1821 4156 32 9 3 AV G 68 1 67 3 65 0 10 38 63 134 1 0 0 Manual Data EntryManual Data Entry
  12. 12. 12 Press Ganey ToolPress Ganey Tool
  13. 13. 13 InterventionIntervention Institutional leadership change (6/04)Institutional leadership change (6/04) Quick “Quick “RegReg” (10/04)” (10/04) Purchased additional equipment (10/04)Purchased additional equipment (10/04) Cabinets for ED roomsCabinets for ED rooms Vital Works ED tracking systemVital Works ED tracking system IV PumpsIV Pumps Improved Lab service availability onImproved Lab service availability on--sitesite (7/04)(7/04)
  14. 14. 14 Intervention (cont’d)Intervention (cont’d) Removed “Saratoga” Satisfaction Tool (7/04)Removed “Saratoga” Satisfaction Tool (7/04) Improved relationships with physician leadershipImproved relationships with physician leadership (6/04)(6/04) Implemented Bedside Registration (10/04)Implemented Bedside Registration (10/04) Increased Radiologist coverage (ProductivityIncreased Radiologist coverage (Productivity Spin off) (9/04)Spin off) (9/04) Enhanced Lab Service and Courier serviceEnhanced Lab Service and Courier service (8/04)(8/04) Implemented Bedside Discharge process(10/04)Implemented Bedside Discharge process(10/04) Orchestrated Psych Pickup by Indian PathOrchestrated Psych Pickup by Indian Path Pavilion (another MSHA facility) (6/04)Pavilion (another MSHA facility) (6/04)
  15. 15. 15 Intervention (cont’d)Intervention (cont’d) Created attitude shift about accepting patientsCreated attitude shift about accepting patients diverted from JCMC (6/04)diverted from JCMC (6/04) Designated patient and family parking for the EDDesignated patient and family parking for the ED (6/04)(6/04) Enhanced ED Room Appearance (8/04)Enhanced ED Room Appearance (8/04) Placed TV’s and phones in rooms (8/04)Placed TV’s and phones in rooms (8/04) Eliminated hand written complaint form (10/04)Eliminated hand written complaint form (10/04) Improved work relationship with EMS crews (inImproved work relationship with EMS crews (in biker bar) (Ongoing)biker bar) (Ongoing)
  16. 16. 16 ImpactImpact ED VisitsED Visits 1,400 1,500 1,600 1,700 1,800 1,900 2,000 2,100 2,200 2,300 2,400 JU L FY03A U G S EP O C T N O V D EC JA N FEB M A R A PR M A Y JU N JU L FY04A U G S EP O C T N O V D EC JA N FEB M A R A PR M A Y JU N JU L FY05A U GS EP T ProjectProject initiatedinitiated
  17. 17. 17 ImpactImpact Acute AdmissionsAcute Admissions 0 10 20 30 40 50 60 70 80 90 100 JU L FY03 AUG SEP O C T N O V D EC JAN FEB M AR APR M AY JU N JU L FY04 AUG SEP O C T N O V D EC JAN FEB M AR APR M AY JU N JU L FY05 AUG SEP ProjectProject initiatedinitiated
  18. 18. 18 North Side ED Length of Stay Baseline and Project 0 50 100 150 200 250 300 7/1/2003 7/15/2003 7/29/2003 8/12/2003 8/26/20039/9/2003 9/23/2003 10/7/2003 10/21/2003 11/4/2003 11/18/2003 12/2/2003 12/16/2003 12/30/2003 1/13/2004 1/27/2004 2/10/2004 2/24/20043/9/2004 3/23/20044/6/2004 4/20/20045/4/2004 5/18/20046/1/2004 6/15/2004 6/29/2004 7/13/2004 7/27/2004 8/10/2004 8/24/20049/7/2004 9/21/2004 10/5/2004 Baseline FY04 FY05 LCLbaseline UCLbaseline Baseline FY04 FY05 ImpactImpact
  19. 19. 19 0 50 100 150 200 250 7/1/2004 7/8/2004 7/15/2004 7/22/2004 7/29/2004 8/5/2004 8/12/2004 8/19/2004 8/26/2004 9/2/2004 9/9/2004 9/16/2004 9/23/2004 9/30/2004 FY05 LOS ImpactImpact NSH ED FY05 Length of StayNSH ED FY05 Length of Stay Removed SaratogaRemoved Saratoga Lab ImprovementsLab Improvements Radiology ImprovementsRadiology Improvements
  20. 20. 20 ImpactImpact ProjectProject initiatedinitiated LWBS NSH ED 0.00% 0.20% 0.40% 0.60% 0.80% 1.00% 1.20% 1.40% 1.60% 1.80% 2.00% Jul-03Aug-03Sep-03O ct-03N ov-03D ec-03Jan-04Feb-04M ar-04Apr-04M ay-04Jun-04 Jul-04Aug-04Sep-04
  21. 21. 21 ImpactImpact Redesigned ED Process FlowRedesigned ED Process FlowPatient Enters NSH ED Clerk calls PCP/LPN/RN to take Patient to Room RN triages Patient and orders approved tests Yes IS ED room av ailable? Registration - Bedside-Registers patient Physician Treats Patient Registration collects copay in ED room Patient is Discharged Patient approaches front desk Clerk "Quick Reg's" patient No Clerk registers patient Patient waits in lobby until room is available RN triages Patient and orders approved tests
  22. 22. 22 76.3 76.5 72.7 74.1 78.7 78.8 79.8 83 82.3 84.3 79.6 70 72 74 76 78 80 82 84 QTR 3 FY 02 QTR 4 FY 02 QTR 1 FY 03 QTR 2 FY 03 QTR 3 FY 03 QTR 4 FY 03 QTR 1 FY 04 QTR 2 FY 04 QTR 3 FY 04 QTR 4 FY 04 QTR 1 FY 05 Quarter Press Ganey Actual ScoresPress Ganey Actual Scores ProjectProject initiatedinitiated
  23. 23. 23 19 18 6 7 27 21 21 28 56 44 65 0 10 20 30 40 50 60 70 QTR 3 FY 02 QTR 4 FY 02 QTR 1 FY 03 QTR 2 FY 03 QTR 3 FY 03 QTR 4 FY 03 QTR 1 FY 04 QTR 2 FY 04 QTR 3 FY 04 QTR 4 FY 04 QTR 1 FY 05 Quarter Press Ganey Percentile ScoresPress Ganey Percentile Scores ProjectProject initiatedinitiated
  24. 24. 24 Hold The GainsHold The Gains
  25. 25. 25 Hold The GainsHold The Gains AA AA BB BB BB CC CC CC
  26. 26. 26 Future Action ItemsFuture Action Items Fully Implement Bedside RegistrationFully Implement Bedside Registration Maximum Utilization of Vital WorksMaximum Utilization of Vital Works Elimination of manual data trackingElimination of manual data tracking Graphical representation of data trendsGraphical representation of data trends Construction and Renovation of EntranceConstruction and Renovation of Entrance Upgrade monitoring equipmentUpgrade monitoring equipment Fully Integrate Clinical Documentation SystemFully Integrate Clinical Documentation System into NSH EDinto NSH ED Full time ED Case ManagerFull time ED Case Manager Improve ED entranceImprove ED entrance
  27. 27. 27 Summary of Results to DateSummary of Results to Date •• Length of stay declining and headedLength of stay declining and headed towards <100 minute LOS goaltowards <100 minute LOS goal •• LWBS below targeted goal of 1%LWBS below targeted goal of 1% •• Press Ganey Score at 65Press Ganey Score at 65thth %tile,%tile, highest %tile ranking since PGhighest %tile ranking since PG instituted (Goal >75instituted (Goal >75thth %tile)%tile)

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