Optimal Staff Mix: staffing compliment Recruitment strategies Full Scope LPN Healthy Workplace Environment Teambuilding Mentorship project Nursing Journal Club Pasqua Renovation Project
Process Improvement Q.I. Teams Process Mapping Eclipsys Patient Streaming Phase 1 (Stream Zone) Phase 2 (Department Streaming/Pods) Phase 3 (Lab & Diagnostics Turn Around Times) Phase 4 (Discharge Planning/Process)
Design Team: Francis Bowen Glen Perchie Marilee Allerdings Lois Vandervelden Helen Grimm Colin Hein Shawn Armstrong Jerry Bell Carla Ismond Stephanie Carlson June Clark Deanna Hubic Ann Park Sheela Smith Suzanne Stringer Mar Elena Guerrero-O'Neil Maryann Grandy Yvonne Harris Lori Nieto Kris Dutchak Kris Norman Donna Akerson Yomi Ajao Christine Jensen Diana Contino Katherine Reller
Challenges: Patient Access Greater than desired Left without Being Seen by the Physicians Admitted patients holding in the ED decreases capacity for ED patients Operational Efficiency Lack of timely performance metrics (to track and trend performance) Greater than desired Arrival to Physician Evaluation Cycle Times Greater than desired Total Turn-Around Cycle Times Human Factors Lower than desired staff morale high turnover and vacant positions Staffing patterns do not match patient arrival patterns
Problem Statement: Regina General and Pasqua Hospital emergency departments patients experience delays in obtaining physician evaluation, intervention and discharge. Eight percent of the patients leave the ED before they are seen by the physician. The delays result in capacity constraints and limited access to services.
HQC Initial Wait Time: 32 Max value = 616 28 Time (minutes) 24 2 16 12 8 4-4 *. Pasqua General Health Quality Council Emergency Department Process Optimization Project
HQC ED Occupancy Time: 6 5 Time (hours) 4 3 2 1. Pasqua General Health Quality Council Emergency Department Process Optimization Project
HQC MD Other Wait Time: 525 Max value = 891 45 Time (minutes) 375 3 225 15 75. Pasqua General Health Quality Council Emergency Department Process Optimization Project
HQC Consult Wait Time: 24 21 Time (hours) 18 15 12 9 6 3. Pasqua General Health Quality Council Emergency Department Process Optimization Project
HQC Bed Ready Wait Time: 55 5 45 Time (hours) 4 35 3 25 2 Oops! 15 1 5. Pasqua General Health Quality Council Emergency Department Process Optimization Project
HQC Causes of Bottlenecks (RGH): Internal vs. External In-ED, 38% Out-ED, 62% Health Quality Council Emergency Department Process Optimization Project
HQC Causes of Bottlenecks (Pasqua): Internal vs. External In-ED, 4% Out-ED, 6% Health Quality Council Emergency Department Process Optimization Project
Bearing Point Bottlenecks (Pasqua) 12 1 8 Time (minutes) 6 4 2 Avg TAKT TIME PH - 15 minutes Reg to Triage Triage to RN Assesment Triage to MD Assesment Md Order to Process Processed to Return Disposition Pt Exit PH Overall Flow 4 37 82 4.5 7 11 27 Sub Process
Bearing Point Bottlenecks (RGH): 1 9 8 7 Cycle time (Minutes) 6 5 4 3 Avg. TAKT Time = 11 minutes 2 1 Reg to Triage Triage to RN Assesment Triage to MD Assesment Md Order to Process RGH Overall 3 34 51 5 83 95 31 Sub Process Processed to Order Return Order Return to Disposition Disposition to Pt Exit
Patient Streaming: # of gowned waiting room spaces Dedicated Assessment Rooms % CTAS 3 seen within 3 minutes Avg. Min. Max. (current) (current) 35.1 33.7 35.9 1 34.9 27.3 37.4 1 1 33.9 31.8 34.9 1 2 54.9 53.5 56.3 2 1 35.9 35. 37.4 2 2 44. 43.2 45.3 Health Quality Council Emergency Department Process Optimization Project
Process of Care
Traditional ED Process:
Patient Streaming:
Patient Streaming (RGH): Current State Streaming % Improvement Median Length of Stay - All Patients 3:15 3.:1 7% Average LWBS 7.6% 3.1% 59% Registration to MD 62 min 48 min 23% CTAS-3 (Urgent) within 3 min 21% 28% 9% CTAS-4 (Less Urgent) within 6 min 39% 54% 24%
Patient Streaming (Pasqua): Current State Streaming % Improvement Median Length of Stay - All Patients 2:55 2:14 23% Average LWBS 8.8% 2.3% 74% Registration to MD 63 min 35 min 44% CTAS-3 (Urgent) within 3 min 18% 41% 28% CTAS-4 (Less Urgent) within 6 min 29% 63% 48% 1 week trial August 26
Waiting Room Inventory (RGH): Saturday 18 16 14 12 1 8 6 4 2 11 12 13 14 15 16 17 18 19 2 21 22 23 Monday 25 2 15 1 5 Current Streaming 11 12 13 14 15 16 17 18 19 2 21 22 23 25 Thursday 2 15 1 1 week trial August 26 5 11 12 13 14 15 16 17 18 19 2 21 22 23
Waiting Room Inventory (Pasqua): Saturday 18 16 14 12 1 8 6 4 2 11 12 13 14 15 16 17 18 19 2 21 22 23 Monday 25 2 15 1 5 Current Streaming 11 12 13 14 15 16 17 18 19 2 21 22 23 25 2 Thursday 15 1 5 1 week trial August 26 11 12 13 14 15 16 17 18 19 2 21 22 23
Impact Total Patient Volume Admissions 5 4 3 2 1 3753 3936 1 8 6 4 2 761 795 Total Volum e April 6 Total Volum e April 7 A dmissions April 6 Admissions April 7 LWBS 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% 6.5% 4.% LWBS April 6 LWBS April 7 Comparing April 26 (no streaming) to April 27 (Streaming 12 hrs/day)
Impact LOS All ED Patients Com paris on Minutes 6 5 4 3 2 1 LOS April 6 LOS April 7 No CTAS Non Urgent Less Urgent Urgent Emergent Resus Savings of 49.4 pt. hours/day Comparing April 26 (no streaming) to April 27 (Streaming 12 hrs/day)
Feedback: Patient rating of Care: 98% satisfactory (39% satisfactory; 59% exceptional) Patient rating of wait time: 94% Acceptable Savings of 49.4 pt. hours/day Staff rating of effective: 94% Effective 6% Undecided
Challenges: 1. In terms of gridlock, emergency department innovation alone cannot fully offset the impact of system problems 2. Seeing sick patients (CTAS 2 & 3) in an ambulatory setting requires significant change in thinking and practice for clinicians 3. For streaming to be effective, a clinician able to make diagnostic, intervention and disposition decisions must be immediately available to the streaming area. 4. Streaming decants the waiting room significantly. By having a dedicated stream zone, pressure to expedite flow is taken off other areas in the emergency department 5. Clinicians do not like make shift space for prolonged periods
Where are we Today? 1. Our system has been continuously over 1% capacity for 34 days (and counting ) 2. We are running 21 vacant RN lines at RGH and 13 at Pasqua 3. We have a number of physician vacancies 4. As a result of a number of extenuating circumstances (potential job action, HVAC failures in the midst of recordbreaking humidity, Outbreaks and bed closures), the emergency department took a significant hit this summer staff frustration and disengagement. We have cut dedicated physician coverage for streaming down to 8 hrs/day and are not progressing to the next stage of streaming implementation until we can secure staffing.
Where are we Today? ED volumes patient visits 6 4 2 Volumes 6 Volumes 7 Stream volumes 6 Stream volumes 7 April 3753 3936 729 may 3929 411 819 June 379 43 681 July 3966 4165 747 April may June July
Where are we Today? LWBS 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% Augus t Septem ber LWBS 26 LWBS 27
Where are we Today? Waiting Room Inventory Sept 22-7 (Saturday) Saturday 25 2 15 1 5 11: 12: 13: 14: 15: 16: 17: 18: 19: 2: 21: 22: 23: Waiting Room Inventory Sept 17-7 (Monday) 25 Monday 2 15 1 5 11: 12: 13: 14: 15: 16: 17: 18: 19: 2: 21: 22: 23: Waiting Room Inventory October 2-7 (Thursday) 25 Thursday 2 15 1 5 11: 12: 13: 14: 15: 16: 17: 18: 19: 2: 21: 22: 23:
Streaming Phase II
Phase I:
Phase I:
Phase II: Pod 1 ------------ Pod 2 ------------ Pod 3 ------------
Phase III: Lab & Diagnostics Kaizens Turn-around times
Phase IV: Discharge Planning and Process Kaizens: Discharge teaching Informed Discharge Transfer to Community Resources
QUESTIONS??
HQC Causes of Bottlenecks (RGH): Internal Factors Urine Transfer to Lab, 8% Wait for Discharge Decisions, 16% MD Other, 27% RN Assessment, 6% RN Other, 14% MD Assessment, 29% Health Quality Council Emergency Department Process Optimization Project
HQC Causes of Bottlenecks (Pasqua): Internal Factors Wait for Discharge, 28% MD Assessment, 27% Urine Transfer to Lab, 3% RN Other, 18% RN Assessment, 4% MD Other, 2% Health Quality Council Emergency Department Process Optimization Project