By Peter Hull, MD; William Webster, MD; Nava Nasr, MD; Jacob Hoover, MD; Gurinder Kanwar, MD; Ashish Tandon, MD; Lisa Barnes, RN; Andrea Perry, RN; and Ellen Sockolov, RN
Transitioning patients efficiently from the emergency department (ED) to the inpatient setting is a challenge for many hospitals. Here's how the Sutter Roseville Medical Center ED (staffed by CEP America) and hospitalists used collaboration and lean methodology to tackle the problem. The following is adapted from a poster presented at CEP America's 2014 annual conference.
When it came to patient throughput, the Sutter Roseville Medical Center (SRMC) ED had a history of strong performance. Then between 2008 and 2013, ED volumes increased by 18 percent from 63,979 to 75,676 with no corresponding increase in capacity. During this period, ED length of stay (LOS) climbed more than 72 percent to over 6 hours, and Press Ganey patient satisfaction scores dipped into the first quartile.
Fortunately, the hospital had embraced lean methodology
, which provided many tools to tackle the problem. During a kaizen event aimed at improving throughput, the ED team identified several factors contributing to the increased LOS. Based on this analysis, they pinpointed turnaround time to admission (TAT-A) as the greatest opportunity for improvement. At that time, admitted patients spent an average of 358 minutes in the department, exceeding the national median of 277 minutes. What's more, time between the "decision to admit" and the completion of admission orders averaged 128 minutes. Surveys suggested these delays were significant drivers of patient dissatisfaction.
The team then identified three main improvement areas that became the focus of the project:
- Understanding and clarifying roles
- Developing standard work around the admissions process
- Timely completion of admission orders
To guide the new project, the hospital formed an interdisciplinary committee of lean coaches, ED providers, hospitalists, registered nurses, case managers, unit secretaries and hospital administrators. The committee used the Plan Do Study Act (PDSA) method to identify and develop key strategies for improvement.
Using these methodologies
, the team set a goal to decrease the length of time between "decision to admit" and completed admission orders by 30 percent to 90 minutes.
In order to achieve this goal, the committee implemented several strategies to improve collaboration and efficiency:
- Standard work is a set of steps to be followed each time a task is done. The team developed standard work to clarify the steps of the admissions process as well as the responsibilities of the ED physician, hospitalist, nurses and other staff members.
- The Fast Pass order set streamlines routine admissions by providing for interim inpatient care until the hospitalist can complete full orders. The ED physician initiates Fast Pass after conferring with the hospitalist to confirm that standardized orders are appropriate.
- Preliminary orders can be initiated by the hospitalist whenever an admission is confirmed. They expedite bed assignment and transfer of the patient to the appropriate setting.
- The patient identification form, a standard work form developed by CEP America, was implemented to identify patients meeting criteria for admission.
In January 2013, the committee launched the new process. Though diligent efforts were made, several obstacles arose, including miscommunications, lack of provider accountability and poor adherence to standard work. By June 2013, time to admission had increased 5 percent to 135 minutes.
At that point, the hospital initiated Thoughtful Improvement of Patient Service and Safety (TIPSS), an in-house process designed to support patient satisfaction initiatives. As part of TIPSS, the hospital CEO and chief nursing officer made weekly rounds to observe the new program in action.
With the increased reinforcement provided by TIPSS, the teams began adhering more closely to the process, and throughput improved steadily. By June 2014, the average length of time between "decision to admit" and order completion had dropped 42 percent to 76 minutes.
Fast Pass order sets were also a success. At the start of the project, providers wrote an average of two Fast Passes per day. As of July 2014, this number increased to 13 per day, accounting for 59 percent of admissions.
Preliminary orders were successfully implemented. However, the team soon realized that Fast Pass orders were more efficient and encouraged hospitalists to use them whenever possible. As a result, preliminary orders are now rarely used.
Patient satisfaction has also improved. Prior to implementation, the ED's mean Press Ganey score was 83.2, placing it in the bottom quartile. By Quarter 3 of 2014, mean overall scores had climbed to 84.9, or the 39th percentile.
SRMC effectively improved its patient throughput and satisfaction through the utilization of lean, kaizen and PDSA. A significant reduction in length of time between "decision to admit" and admission order completion has been achieved and maintained. Patient satisfaction has also improved.
Open communication and collaboration was vital to this success. In order to overcome the common conflicts that arise between ED providers and hospitalists, it is necessary for each party to understand and appreciate the pressures affecting the other. The development of standard work helped to clarify the needs and roles of each specialty, resulting in improved working relationships.
Accountability and consistency are also crucial. Initial interventions were unsuccessful. However, once weekly administrative rounding was implemented, the team made rapid gains and began to see value in the process. Continued rounding ensured that improvements were sustained until the changes became hardwired into the culture.
Involving key players and department leaders is critical to the success of any process change. As leaders change their behaviors, the rest of the organization is affected as more people become engaged in problem solving rather than creating shortcuts and workarounds. The success of this kaizen event has established ownership amongst the key players and is serving as an example to other lean initiatives at SRMC.
Since implementation wrapped up in fall 2014, SRMC's hospitalist and emergency medicine teams have continued to follow the new process. Several of their interventions, including the Fast Pass order set, were incorporated into the hospital's new EHR system, which went live in January 2015. Turnaround times increased slightly during EHR implementation (a common side effect) but soon returned to normal levels and have remained steady since.
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