A cllabrative lean based apprach t imprve thrughput and reduce/eliminate ambulance diversins Unin Hspital f Cecil Cunty Prgram/Prject Descriptin, including Gals: What was the prblem t be slved? Hw was it identified? What baseline data existed? What were the gals hw wuld yu knw if yu were successful? We had excessive yellw and red alert hurs with ambulance diversins which was created by pr prcesses with husewide thrughput and slw transfers f patients ut f the ED. Yellw alert is indicative f the Emergency rm being full t capacity and Red Alert is an indicatin t lcal ambulances that patients in ur cmmunity are t be diverted t ther hspitals which was a dissatisfiyer and a delay in care fr patients in ur cmmunity. We were visited by MIEMSS (Maryland Institute fr Emergency Medical Services Systems) in March after receiving a frmal letter f cncern t understand ur wrkflw prcesses and ffer slutins that were t be embedded in ur actin plan with a fllw up visit in 6 mnths. Yellw and Red Alert hurs were reprted t the State but nt internally mnitred r tracked fr prcess imprvement. Baseline data are as fllws... Alert Utilizatin Summary The gals were: 1) t first f all educate all the staff abut maintaining a bed ahead philsphy and MIEMSS. 2) reduce red alerts and ambulance diversins 3) imprve husewide thrughput 4) engage every level f staffing CNAs t staff RNs t CNO
5) Imprve verall cmmunicatin Success was measured by a successful 6 mnth fllw up visit t assess ur rganizatin fr imprvement. Success is als measured by the implementatin f new prcesses t imprve ur prcesses that have held ver time and finally by the 3 mnth eliminatin f diversin alerts which n lnger put us in jepardy f lsing ur base statin in the Emergency Department. We als used t average 3-5 cmplaints t the huse supervisrs and we have nly had 1 ver the past 3 mnths. Our number f delays fr ED transfers fr >120 minutes has als decreased by 50%. Prcess: What methdlgy r prcess was used t develp the Slutin? We implemented a strategy using Lean Methdlgy Kaizen meetings with staff and directrs t understand knwledge deficit and variability with prcesses Plan Individual and grup meetings with frntline and leaders. Emails t staff t infrm staff f rapid cycle test f new bed ahead prcess D trialed new prcess fr 14 cnsecutive days. Rle defined actins that cvered all psitins/rles huse supervisr, charge RN, CAN, managers and CNO. Check Daily electrnic huddle initiated daily by the CNO fr every staff persn t prvide feedback (psitive and negative). Included weekends and ff shifts. Act- full debriefing at cnclusin f rapid cycle test. Successful implementatin f these strategies resulted in permanent additins t imprve thrughput: Slutin: What Slutin was develped? We instituted an Organizatin wide Bed ahead apprach in 2 weeks Hw was it implemented? Successful implementatin f a rapid cycle test and cmmunicated as nursing apprach and philsphy. Measurable Outcmes: What are the results f implementing the Slutin? Eliminated ambulance diversins. Please see belw.
Red Alert Hurs Trending Prvide qualitative and/r quantitative results t data. (Please include graphs, charts, r tls). Sustainability: What measures are being taken t ensure that results can be sustained and spread? We regularly review f huse supervisr reprts, cuncil structure. We have als included this measure as ne f fur verall nursing divisin gals fr cntinued imprvement and wnership. Rle f Cllabratin and Leadership: What rle did teamwrk and cllabratin play in the Slutin? Huge impact invlving all staff in the rapid cycle test and sharing the results. Engagement frm all stakehlders t include physicians. What partners and participants were invlved? Physicians, husekeeping, IT, Materials Management Was the rganizatin s leadership engaged and did they share the visin fr success? Yes, was initiated by CNO. Hw was leadership supprt demnstrated? Daily email huddle initiatin and ging t the gemba (walking the flr), emphasizing that any staff member can "pull the chain n the bus" if they feel they are nt prviding safe care. Innvatin: What makes this Slutin innvative? We were able t implement 6 strategies in a very shrt amunt f time withut numerus meetings and discussins t imprve thrughput. Immediate change in culture twards managing patient thrughput that affected every level f care, medical staff and nursing ancillary partners. What are its unique attributes?
Brad cllabratin. Nn punitive challenging and questining f prcesses and suggestins fr imprvement. Drastic results fr imprvement. Overall summary f ur rapid cycle test is attached which includes what strategies were implemented permanently, psitives, negatives and future imprvement strategies that are being wrked thrugh at ur care efficiency cmmittee. Cntact Persn Title Katie Bstn-Leary, Chief Nursing Officer Email kbstn-leary@uhcc.cm Phne 4434061677
MIEMMS Rle defined Rapid Cycle Test Gal: Build a systemized multi-level state f urgency, wnership and accuntability fr pulling admits ut f the ED that is patient centered, metrics driven and cllabrative. Plan: Rapid Cycle test fr 10 weekdays starting August 6 th. Rle defined expectatins are as fllws: Huse Supervisrs Imprve charge nurse cllabratin with patient placement Imprve and enhance cmmunicatin at bed meetings Enhance ability t prvide supprt and guidance t nursing staff Develp buddy system t delegate tasks as apprpriate Will have nursing leadership supprt during ff hurs Charge Nurses 1) Will be empwered t make staffing decisins based n acuity and nt be hampered by staffing matrices 2) Will nt flex staffing dwn ther than what was agreed upn with nurse managers 3) build staffing fr charge nurses t be ut f the numbers r take n a cmparatively lesser assignment versus a full assignment lad. 4) Always able t request the need fr a huddle if deemed necessary fr safe care. 5) Adpt a bed ahead philsphy Always plan where yur next admissin will be Plan ahead if we nly have ne semi-private pen Think wh culd we mve frm a private rm t pen up a private ne Staff the unit a bed ahead t anticipate admissins and facilitate timeliness f admissins If acuity is high cnsider altering staffing t match demand It is kay t bring in that extra RN r C.N.A. if the acuity is high 6)Cllabrate with the huse supervisr t assign the best bed placement fr the unit and the patient 7)Facilitate the primary nurse receiving reprt frm the ED in a timely manner Prvide the primary nurse with the admissin inf as sn as yu get it When giving the primary nurse the admissin ask if they will have time t call the ED within the next 20 minutes, if nt then take reprt n that patient When the ED r huse is at full capacity, try t have smene call fr reprt right away, withut delay Nurses 1)Yu play a strng rle in helping t get the patients t their rms quickly and helping with the flw f the whle hspital 2)Assist by fllwing thrugh and calling the ED fr reprt within 30 minutes f when the bed is psted Remember there is a delay frm the time it is psted until the admissin gets t yu.
Try t call the ED when yu receive the admissin r the first chance yu can when yu are freed up frm the task yu are ding If yu are unable t take reprt with 20-30 minutes then delegate this t yur charge nurse 3)If yu have a bed pen r nt a full assignment, always be prepared that yu will be receiving a patient 4)Any assistance yu have in getting ur patients discharged and discharged sner is always helpful C.N.A.s 1)Yu als play a strng rle in helping t get patients t their rms 2)If yu culd assist with helping t get patients ready fr discharge 3)When we are full it is helpful if yu strip dwn the beds and place any unused r discarded items int the trash t help ur husekeepers 4)When patients arrive, it is a team effrt t get ur patients settled int their rms Unit Clerks 1)Any help yu can give t help the patients be discharged sner and faster is always helpful 2)If the ED calls fr reprt after 30 minutes make sure that smene takes reprt n that patient 3)If yu ntice the Ed calling back mre than nce, let the Charge Nurse knw Nurse Managers 1) cnnect with charge nurses first thing in the am and thrughut the day t supprt, cach and mentr "bed ahead" philsphy and ffer suggestins - census, ptential discharges, hypthetical planning fr next patient, resurce management with maintaining staffing ratis 2) attend bed meeting if at capacity t supprt and/r cver charge nurses 3) carry phnes fr 20 minutes while charge nurses attend bed meeting 4) initiate a huddle at any time there is a cncern Directrs 1) if at capacity, directrs shuld attend and prvide silent and visible supprt 2) help remve barriers and change management 3) end f day email daily debrief 4) call a huddle if needed Interim CNO 1) initiate end f day email debrief at 1600 daily 2) setup meeting in ne week pst RCT implementatin t debrief (if needed) and after 2 week implementatin Bed Meetings Finite perid t start and end n time. Target 20 minutes. Minimize phne interruptins - manager will cver and carry phnes while charge is at bed meetings. If manager is unavailable, must silence and make staff aware that they can reach manager if there is an emergency that cannt wait.
Handff/Reprt Prblem Reslutin Any cncerns with patients being placed n unit shuld be managed with manager/directr r the huse sup during ff hurs. If cncerns are nt being addressed, escalatin shuld be managed with the manager/directr n call. It shuld never be managed with the nurse giving reprt. Always take reprt and Measures f success ED hlds ttal hurs # f hlds Decisin t admit t time leaving the ED Decisin t admit t rder written Staff perceptin
RCT Debrief 8/26/13 Psitives One example f ICU/PCU RN taking patient frm ED t ICU/PCU Situatin-based apprach fr face t face handff reprt fr increased acuity patient MSU (OBS) rientatin Charge RNs bed ahead assigning assignment mre efficient RN satisfactin Overall psitive cllabratin Grwth Open cmmunicatin, felt safe In patient units cnsistently pulling pts. (calling fr reprt) frm ED Extra staff available in huse t help with flw/admissins Extra staff Built relatinships Patient Centered Balancing vlume Initiative displayed hspital-wide teamwrk acrss all units Lw census Out f the bx ideas We apprach Very prud Sitter schedule Buddy system Discs Remved respnsibility frm Huse Sup s Sustain Sitters schedules Buddy system Electrnic huddle grup PCS, Nurse Managers, Huse Sups, AHI, Dc Leads) Recap with Clinical Educatin, Charge Nurse Charge Nurses bed ahead, making assignments OBS/MSU patients Charge Ntify Huse Sups prir t Flex autnmy f calling help if needed Admissin RN: 1. Assigned lwer census (department/husewide) 2. Phne 3. Cmmunicate t all charge RN s 4. Huse sup dispatch 5. Discretin Agency RNs Flat as needed Keep Ging? Increase census; Daily cmmunicatin / huddle Check in with frnt line staff
Negatives Really wrried when census is high (went well, help was great in huse) Staff being pulled dissatisfyer Will be impacted by cmpeting pririties Missing target fr ED Admits Rm fr Imprvement Huse Sup data cllectin Reduce email vlume Expectatins fr all staff (reprt, sister units) Call the unit ne the patient leaves the ED RN s & CAN s being pulled prcess, n barding Have admissin/rn wrk frm ED Crss training (cntinuing ED) share day Batching/batching impressins Physician cverage? 1 ED MD/1 Hspitalists Target fr ED admit review data Mre wrk with earlier discharges Ambulance (review cntract) supprting with ur staff Capacity alert cmmunicatin gap t frnt line (tracker?) Guidelines fr use f sitters RRT prcess (days vs. nights)