By Kathleen Munro, BSN, RN; Veronica Palustra, MSN, RN; and Lilian Wu, MSN, RN
Team celebrates 284 minutes, exceeding the goal! Left to right: Chris Tarver, Colleen Panec, Roberta Hernandez, Lilian Wu, Kathleen Munro, Jeanne Lee, Linda Copeland, Alicia Potolsky, Carolina Nader and Lotta Mae Alba.
In today's cost-conscious environment, hospitals are striving to do less with more. Many are attracted to lean, a philosophy that emphasizes the creation of value and elimination of waste. However, becoming a lean organization takes time and requires a great deal of dedication from administration, providers and staff.
That being said, the journey to lean need not take decades. The experience of El Camino Hospital in Mountain View, Calif., shows it's possible to achieve meaningful change relatively quickly using lean methodology.
Since 2013, the El Camino Hospital's interdepartmental lean team has implemented a series of practice changes, resulting in incremental improvements in throughput and patient satisfaction. Among their successes has been a significant reduction in emergency department length of stay (LOS) for admitted patients, a measure that was added to the Centers for Medicare and Medicaid Services' (CMS) core measures in 2014.
The following post is adapted from a poster presented at CEP America's 2013 annual conference as well as the team's subsequent presentation at the Summit on Evidence-Based Practice in San Antonio, Tex.
Prolonged length of stay (LOS) in emergency departments (EDs) is a national crisis. LOS is measured as the number of minutes from when the patient arrives at the ED to the time the patient is discharged home or admitted to a hospital unit.
The El Camino Hospital administration recognized that lean could address its strategic goals of Quality, Service and Affordability. To this end, administrators reached out to leaders in key departments about implementing lean methodology. Their first goal was to reduce ED LOS for admitted patients to 286 minutes or less.
During the first phase of the project, which began in spring 2013, an interdisciplinary team of front-line staff from ED, medical surgical and telemetry units collaborated to define safe, timely and efficient care to improve the patient experience while decreasing LOS.
The Institute of Medicine (IOM) described ED crowding as a "national epidemic," because overcrowding compromises the patients’ experience by delays in treatment and higher risk for errors. These risks increase inpatient LOS, cost to the patient, cost to the organization and mortality and morbidity of the patients. For these reasons, CMS added ED LOS for admitted patients to its 2014 core measures.
Furthermore, The Joint Commission cites poor communication as the number one root cause of sentinel events, and poor communication is an even greater cause of patient dissatisfaction than actual LOS. Patients become dissatisfied when they do not perceive a culture of caring and safety.
Front-line staff participated in a rapid process improvement workshop (RPIW) to implement solutions utilizing lean methods (a set of management practices from the Toyota Production System) to improve efficiency and quality for patient throughput.
By holding themselves accountable to this process, they eliminated waste through identifying non-value-added activity (NVA) to achieve a more positive patient experience.
Based on its initial RPIW findings, the team piloted the following solutions:
- Patients were brought back to an exam room immediately after being triaged, driven by room availability. A provider and nurse met with the patient simultaneously to discuss the plan of care, improving communication while keeping the patient informed.
- Direct care nurses collaborated with team providers to create "the plan of care" form. This was handed to each patient, providing the name of the provider, nurse and estimated wait times for lab results and procedures.
- A standardized communication process was developed in which inpatient nurses reviewed the ED patient handoff summary in the electronic medical record (EMR) and would communicate with ED nurses for questions or updates, improving organization and collaboration for meaningful inpatient transfer.
- ED physicians and hospitalist groups collaborated on specific diagnosis appropriate for bridging orders as well as standardizing the admission order set for safe and efficient throughput.
Teamwork — emergency department team members in daily huddles. Lean team members, left to right: Lotta Mae Alba, MS, RN, CNS, ED manager; Audrey Prairo, RN; Veronica Palustra, MSN, RN; Laura Cook, MD, ED medical director.
Front-line staff and management met weekly to review data, successes and issues. Collaboratively, the team decided on processes based on real-time data and feedback. Results were shared in daily huddles for immediate feedback and solutions.
El Camino Hospital's LOS goal for admitted ED patients was 286 minutes (the national average is 274 minutes).
In less than 90 days, the average LOS (Feb 2013 – May 2013) decreased from 330 to 283 minutes. Within 15 months, it had dropped to 270 minutes.
The hospital also saw a steady increase in the use of bridge orders:
In addition, important patient-centered care measures increased by 9 percent over 6 months.
Key learnings from the ED LOS improvement process at El Camino Hospital include:
- Including all departments in transitions of care is an integral part of effective practice change. An interdisciplinary team approach helps ensure that all stakeholders can participate in designing solutions.
- Real-time data, feedback and commitment to daily huddles created the culture of transparency to sustain continuous improvement. At El Camino Hospital, turnaround times were emailed to team members, displayed in the department and shared at huddles.
The interdisciplinary lean team at El Camino Hospital has continued to apply lean methodology to new process improvement goals:
- ED time to provider
- ED turnaround time to discharge
- Patient satisfaction in the ED
- Interdepartmental communication
Perspectives hopes to report on these projects in future posts.
Institute for Healthcare Improvement (2011). Going lean in health care. Retrieved from: http://www.ihi.org/resources/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx.
The Joint Commission (2007). "What did the doctor say?:" Improving health literacy to protect patient safety. Retrieved from: http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf.
National Research Council (2007). Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press.
Lotta Mae Alba, MS, RN, CNS, Emergency Department Manager
Dr. Laura Cook, Emergency Department Medical Director
Vivian Low, MPH, RN-BC, FPCNA, Chair, Nursing Research Council
Anne Pauselius, Quality Data Coordinator
Chris Pratt, Senior Director, Performance Improvement
El Camino Hospital administration, staff and PaCT team
About the Hospital
El Camino Hospital is a nonprofit organization with hospital campuses in Mountain View, California and Los Gatos, California. Our hospitals have served communities in the South San Francisco Bay Area for more than 50 years. We strive to provide superlative care by focusing on patients’ needs, rather than on shareholders’ demands, and by incorporating the latest, proven medical technology and attracting the best medical staff and affiliated physicians.