2. Breaking down cultural walls
preventing superior ED
performance
Christopher Walker, MS, RN, NP, CNS, CCRN, CEN
Director Emergency Services
Sharp Memorial Hospital
San Diego, CA
christopher.walker@sharp.com

3. Faculty Disclosure
• Session goal: Empower ED leaders and
staff to drive a cultural revolution in their
departments.
• Conflicts of interest: None
• Employer: Sharp Healthcare
• Sponsorship / commercial support: None

4. The Emergency Nurses Association is
accredited as a provider of continuing
nursing education by the American
Nurses Credentialing Center’s
Commission on Accreditation.

5. Reflection
There are three constants in life….
CHANGE
CHOICE, and
PRINCIPLES
- Steven Covey

6. Sharp Memorial Hospital
• Community Hospital
• Level II Trauma Center
• Base Station (Radio Room)
• 400 operational beds
– 48 ICU Beds (+10 overflow)
– 44 Short-Stay/Observation
• Private Inpatient Rooms
• 49 Bed ED
– 40 ED
– 4 Trauma
– 2 Decon
– 3 Quick Care

7. Sharp Healthcare’s Vision
Sharp Healthcare’s vision is to be the best
health system in the universe.
The best place to work
The best place to practice medicine
The best place to receive care

8. Why must we change?
Regulation
Overcrowding
Patient Satisfaction
Tradition

9. Regulatory Scrutiny
• Mandates to provide care (EMTALA, CMMS)
• Fear of retribution and litigation
• Refusal to pay (Medicare and Private)
• $$$ tied to patient experience
• $$$ tied to quality (readmissions, mortality)
= Higher Cost of Care

10. Overcrowding
• Full lobbies have
become the norm, not
the exception
• It’s a daily phenomenon
• More patients than beds
• Bypass overutilization

11. Patient Dissatisfaction
• It’s the typical expectation for ED care
• High ER wait times and long length of stays
• Patients leaving without being seen or treated
• Perception of poor quality of care
• Dissatisfaction continued for admitted patients

12. Tradition
• Rarely patient centric
• Bad, old, or no science behind practices
• Unable to adapt with healthcare evolution
• Divides a unit across generational lines
• Settling for Good Enough
• “Its the way we have always done it”

13. No Change, No Change
• Sharp Experience starts in 2001
• 2009 – moved into beautiful new building
• No Change in Experience
• Deep divide between staff and leadership
• Stuck in daily survival mode

14. The Lean Intervention
• Focus on the patient experience and improve
ED patient satisfaction
• Increase efficiency through waste reduction
– Reduce ED patient LOS & lobby wait times
• Improve staff satisfaction and morale
– Education, team development, standard work
• Improve Physician Satisfaction
– Growth in volume and income

15. What is Lean?
A methodology that focuses on
• Improving Workflow
• Eliminating Waste
• Delivering Value

16. The Toyota House from Graban, M. Lean Hospitals: Improving Quality, Patient Safety, and
Employee Satisfaction, New York, NY: Productivity Press, 2009, p74.
The Toyota House

17. The Toyota Way Leadership Model
True North Values
Challenge
Kaizen Mind
Go and See
Teamwork
Respect for
Humanity
Commit to
Self
Development
Coach and
Develop
Others
Support
Daily Kaizen
Create
Vision and
Align Goals

18. True North Values
• Challenge
• Kaizen Mind
• Go and See
• Teamwork
• Respect for Humanity

19. Commit to Self
Development
I am always doing that which I can not do, in order
that I may learn how to do it.
-- Pablo Picasso

20. The Self Developer
 Personal motivation and initiative
 Commitment to lifelong learning
 Emotional intelligence
 Seeks out mentorship
 Works through the novice to expert cycles
Shu Ha Ri

21. Domains of Self-Development
Attitude
Know Why
Knowledge
Know What
Skills
Know How
Commitment
Process
Purpose
ABILITY

22. Leader and Team Study

23. Coach and Develop Others

24. Building New Leadership Habits
• Coaching Self-Development
• Role Model True North Values
– Avoid office and boardroom management
– Respect your staff by engaging them
– See and ask, don’t tell or demand
• “Nurture and Severely Challenge” your high
performers

25. Change Readiness

26. Change Management Support
• Lean Six Sigma Master Black Belt
• Green Belt Training on-site
• Lean Leader Development
– Frequent Mentorship Meetings
– Break work into components for easy wins
– Change Management Education
• Leader visibility and rounding with focus

27. Information Sharing
What are the challenges?
What is working well?
RNs and MDs given
feedback on change
initiatives.
People Engagement

28. • Internal ER
– Top Pod Leader
– Top Team
Member
• External ER
– First Attempt
Report (given by
ER RN)
– Top Charge RN
LeanER
Reward and Recognition

29. Support Daily Kaizen
Build local capability for continuous improvement

30. Philosophy of Continuous Improvement Over Time
S
K
S
K
S
K
S
K
S
K
K = Kaizen (‘good change’ in Japanese)
S = Sustain through Standardization
Lean Implementation Process
No Sustain = No Gain

31. Managing to Learn
with the Kaizen Events, Try-storms, and A3
• Kaizen Event – Full day(s) documented the current,
ideal, and target states.
– Used these to take big process steps
• Trystorms – Rapid Cycle Improvement
– Model team, area that would test new processes and
measure outcomes
– Nimble enough to change midstream
• A3 – Individual/Small Group PI
– Used on smaller process issues within the value stream

32. “All hands, hands on, all stakeholders.”
1. Walk the process
2. Brainstorm Wastes
3. Sensing with coworkers
4. Integrate Lean philosophy
5. Test the new process
6. Create Standard Work
7. Seek feedback (Muda Board)
8. Reanalyze data
Solutions Through Kaizen Events

33. Communication flow
Patient flow
13% value
added activities
Value Stream Mapping

34. Intra-department Improvement
 Team Development (Developing People)
 Team structure by pod*
 Team member responsibilities (Standard Work)
 Team leadership
 Team accountability
 Physician accountability
* A Pod is the functional unit of our department. There are
5 pods within our department

35. Intra-Department Improvement
 Targeted Solutions
 Team Leaders with Self-Sufficient Teams
 Top of the Hour Huddles
 Co-assessment/Co-discharge
 Bedside Triage
 Work Station Re-Configuration
 ED Patient Room Standardization
 Diagnostic Turn Around Time

36. Hospital Wide Improvement
 Admission Throughput
 Started as service recovery
 Alignment with strategic plan and organizational
goals
 Nurse Transport & Bedside Hand-off
 Rapid Cycle Improvement
 100 day campaign to 60 minutes (order to bed)

37. Sustaining
• Strategic Planning and Priorities
• Ongoing Learning
• Frontline Engagement
– Lean Meetings – Every 2-4 weeks
– 2-4 Projects per year
– Town Halls – Monthly with Lean report out
– Muda Boards – Ongoing

38. Current Efforts
• Growth opportunity is the discharged population
• Longer lobby waits for the “lowest acuity”, but…
– Patient satisfaction surveys
– Risk of deterioration
– Experience suffers
• Utilization of Observation Unit – Trauma Obs
• Psych Boarding

39. Create Vision and Align Goals
Alignment of goals vertically and horizontally

40. Target Selection Criteria
• Reduce ED LOS to < 3hours
– Identified the relationship between a patient experiences less
than 3 hours and satisfaction scores reaching our goal of 90th
percentile performance.
2009 Overall > 3hr <3hr
Overall ED Patient
Satisfaction Rank
57th 40th 95th
Mean Score 84.3 82.8 89.1
N 3936 2883 1053

41. Targets
Sharp Memorial – All Nursing – CNO to ED Clerk
• Admission Throughput – Order to Occupy < 60min
• Hospital-wide Patient Satisfaction > 90th
Emergency Services
• Total ED LOS – Door to Exit < 3 hours
• Total LOS for Quick Care – Door to Car < 90
(2015)
• ED Patient Satisfaction > 90th

42. Admission Throughput
216
128
77
60 55
61 57
0
20
40
60
80
100
120
140
160
180
200
220
240
FY2009 FY2010 FY2011 FY 2012 FY2013 FY2014 FY2015
Minutes
SMH Emergency Department
Admission Throughput
Goal is < 60 minutes
Admit Order to In Bed Goal ≤ 60"

43. LOS and Patient Satisfaction
5.6 4.90 4.70 3.80 3.30 3.30 3.5 3.2
27
69
88
97 99 99
96
88
0
10
20
30
40
50
60
70
80
90
100
0
1
2
3
4
5
6
FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY to date
2015
PercentileHours
SMH Emergency Department
Length of Stay and Patient Satisfaction Percentile Rank
LOS Pt Sat

44. LOS and Census
5.6
4.90 4.70
3.80
3.30 3.30 3.35 3.20
47,137
52,173
57,605
63,290
69,799
73,670
78,318
87,680
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
0
1
2
3
4
5
6
FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015
Hours
SMH Emergency Department
Length of Stay and Total Census
LOS FY Census
Annualized total

45. Changing Culture
 Align your goals and behavior with your principles
 Structure yourself and your team for continuous change
 Engage the early adopters and enlist the frontline to
drive the change
 Manage the CAVEMEN with < 10% of your time
 Coach yourself and your staff to be experts in
performance improvement
 Innovation and Adaptability leads to happy patients,
physicians, and nurses

46. Thank you for your attention
christopher.walker@sharp.com