TEAM ASSESSMENT PULL PROCESS CHILDREN S HEALTHCARE OF ATLANTA AT SCOTTISH RITE

Publication Year: 2011 TEAM ASSESSMENT PULL PROCESS CHILDREN S HEALTHCARE OF ATLANTA AT SCOTTISH RITE Summary: The Team Assessment Pull Process (TAPP) is a technique to redesign emergency department patient flow to reduce waiting and delayed decision that results in wasted time for patients, nurses and physicians. Under the TAPP system, the patient is seen by the physician and nurse immediately after being placed in a room Hospital: Children s Healthcare of Atlanta at Scottish Rite Location: 1001 Johnson Ferry Road NE Atlanta, GA 30342 Contact: Marianne Hatfield, MSN, RN, CENP System Director of Emergency Services Marianne.Hatfield@choa.org Category: A: Arrival C: Clinician Initial Evaluation Key Words: Wait times TAPP Lean 5S Hospital Metrics: (Taken from the American Hospital Directory) Annual ED Volume: Approximately 90,000 Hospital Beds: 234 Ownership: Non Profit Trauma Level: I Teaching Status: Yes Tools Provided: A3 Process Improvement Question Template A process improvement tool for a team of frontline staff to use for evaluating their process cycle time. The A3 denotes the size of the paper used (11x17) for the one page process improvement summary. The problem and recommended solutions all fit onto this one size paper to help people focus their thoughts and hone in on the one area for improvement. Following the A3 in order (folding over the solutions slide) keeps staff from jumping ahead to solutions before adequately defining the problem. TAPP Algorithm This tool is an algorithm used in the emergency department by staff as a step by step flow chart to direct the Team Assessment Pull Process. Clinical Areas Affected: Triage Fast Track Main Emergency Department Staff Involved: Physicians Nurses Front line staff Copyright 2002 2012 Urgent Matters 1

Innovation The Team Assessment Pull Process (TAPP) is a technique to redesign emergency department patient flow to reduce waiting and delayed decision that results in wasted time for patients, nurses and physicians. Under the TAPP system, the patient is seen by the physician and nurse immediately after being placed in a room. The nurse completes the treatment plan ordered for the patient before being assigned to the next patient. Results Using TAPP, Scottish Rite was able to reduce the overall median length of stay (LOS) in the ED from 153 minutes to 125 minutes. Excluding fast track patients the median LOS in the ED decreased from 192 minutes to 167 minutes. TAPP has also allowed the Scottish Rite ED to reduce median door to provider time from 44 minutes to 28 minutes. They utilized median as a measure of central tendency for comparative data as opposed to mean or mode in order to properly assess the skewed distribution and account for outliers in the data. One comparative measure used was ED LOS for Discharged Patients. The SR ED consistently performs as one of the top three EDs in this measure, despite their annual volume being close to three times as high as the other two top performing hospitals. Although not part of the initial project aim, decreasing LOS led to a decrease in LWBS. Decreasing LWBS improves overall revenue, because it increases the number of billable patients who remain for treatment in the ED. They have also seen an increase in overall customer satisfaction scores. Press Ganey scores for the ED have been in the 99th percentile ranking for overall rating of care for eight out of ten consecutive quarters. From The Experts Patients are no longer put in rooms simply because one is available. They are now pulled to a room only when a physician and nurse are both ready to start their treatment plan. The patient and their family are not asked redundant questions because the physician and the nurse complete the assessment together. The patient and family are able to hear the physician and nurse verbalize the plan of care. Marianne Hatfield, RN, MSN, CEMP, System Director of Emergency Services Timeline Children s Healthcare of Atlanta was able to use Lean methodology; a rapid process improvement strategy derived from the Toyota Production System to improve efficiency in the Scottish Rite ED. Lean requires a brief but intense time commitment up to one week of consecutive full day meetings followed by rapid process implementation trials after the week of process re design. At the end of this week, the team trialed a new, standardized process, front line staff identified obstacles and barriers, and the team spent the next 30 days redesigning the process and educating staff and physicians on the upcoming changes. The resulting standardized process was named the Team Assessment Pull Process. Innovation Implementation After visiting Seattle in January, 2008 to observe how Seattle Children s Hospital implemented Lean methodology, Scottish Rite established a Lean team, comprised of frontline staff nurses, physicians, and ED technicians who undertook the process review and re design work. Lean places heavy emphasis on frontline staff involvement in process improvement. By mapping their processes, they were able to identify variation and waste. Waste was defined as any activity that was not seen as value added by a customer. In the ED, this included redundant processes and re work; searching for supplies needed for patient care; deciding which patient to see first when there are multiple sets of orders; interruptions in care; making a patient travel for a procedure; and any delays for any reason. Copyright 2002 2012 Urgent Matters 2

The team decided to focus on redesigning the flow for a segment of the ED visit with the most variation and waste. Lean emphasizes standardizing wherever possible because without a standard, you cannot measure or improve. For Scottish Rite, that one segment was the initial nurse and physician assessment. Staff and physicians recognized there was a great deal of variation and waste in their assessment processes and particularly in terms of clinician coordination. Previously, the ED filled every available room as patients arrived for treatment, regardless of whether sufficient staff or providers were available to see the patients immediately. They determined that this process resulted in tremendous variation in treatment start times and bottlenecks in the treatment rooms. There was no standard procedure for how a patient was: 1) Assessed by a physician 2) Assessed by a nurse 3) Provided with a treatment plan that was immediately shared between disciplines 4) Provided treatment as soon as the physician determined a plan In TAPP, work is pulled only when resources (a matched provider and RN who are both ready for new work) have been identified to start the patient care process. Pulling patients into an available room only when the provider and nurse are ready to begin the treatment plan eliminates the waste of mismatched resources and having patients wait for resources. TAPP standardized the arrival to room and also saves patients from having a redundant assessment, because the initial physician and nurse assessments are completed at the same time. It also allowed for coordinated communication of the plan of care and an immediate treatment start for the newly assessed patient, because the nurse is aware of the treatment plan as soon as the physician determines that plan. Patients do not wait in a treatment room or experience delays in care provision because the nurse escorts them to the room and the physician meets them in the room. The 5 S s In order to further expend the benefits of TAPP the ED adopted the 5S system, which involves: Sort: Remove from workplace all items that are not needed for current operations and activities. Set In Order: Arrange items needed so they are easy to use, and label them so they are easy to find and store. Shine: Keep the workplace tidy, sweep floors, clean equipment, and generally make sure everything stays clean. Standardize: Adopt a method of working to ensure the first three pillars are maintained. Sustain: Ensure and make it a habit that everyone adopts and carries out correct procedures. The 5S System was used to standardize the supplies in patient treatment rooms, both in the cabinets and at the head of the bed. Staff members and physicians provided input into what they needed the most when treating patients and supplies were organized to be accessible and useful. There are visual cues, such as lines and labels that indicate the par level and when a supply needs to be restocked. Cost/Benefit Analysis Utilizing Lean allowed the SR ED to take care of more patients with the same number of staff member. The salaries per unit of service (sal/uos) decreased 10.5 percent. Copyright 2002 2012 Urgent Matters 3

Advice and Lessons Learned o o o o Lean Methodology can only be successful if you engage front line staff members on your improvement teams. Front line staff members understand the workflow better than managers/leaders, ensure that process changes are practical and sustainable, and engage other front line staff. Process change cannot happen without physician buy in. Engage your physicians and insist that they be part of the team. Improving efficiency in process flow elevates staff engagement. Because they are an integral part of the process redesign, they become champions of the process change, helping you overcome the natural resistance that occurs with any change implementation. Post your data regularly and celebrate your successes. This motivates your staff to keep going, even when there is vocal resistance in the early part of a change implementation. Tools to Download A3 Process Improvement Question Template TAPP Algorithm Related Resources Urgent Matter E Newsletter Volume 7, Issue 3: Innovations: Team Assessment Pull Process TAPP Outputs Copyright 2002 2012 Urgent Matters 4

Title: Fresh Eyes: Subject Start Date: Team: Expert(s): Revision Date: Owner: Revision #: Coach: Problem/Issue Goals/Targets Background FUTURE STATE Target Condition Current Conditions CURRENT STATE Recommended Actions Problem Analysis CHECK / ACT DO PLAN Implementation Plan Follow Up Stakeholder Signatures: PDSA A3 TEMPLATE

Title: What are you talking about? Fresh Eyes: Subject Start Date: When did you start? Team: Expert(s): Revision Date: Latest Draft Owner: Revision #: How many? Coach: Problem/Issue Goals/Targets WHAT problem are you trying to solve or analyze? State the specific target(s) State in measurable or identifiable terms CURRENT STATE Background WHY are you talking about it? WHAT is the business case? Be very concise - communicate WHY you are addressing this issue. Current Conditions WHAT is going on? Use facts, dates, etc Be visual - use Pareto charts, process maps, sketch pictures Make the problem clear Problem Analysis Use the simplest problem analysis tool that will suffice to find the root cause of the problem Five whys, Fishbone diagram, tools from Six Sigma or other tool of your choice CHECK / ACT DO PLAN FUTURE STATE Target Condition What should the future look like Be visual - use process maps, sketch pictures Indicate proposed changes Recommended Actions List your proposed changes or countermeasures to the problem Implementation Plan Who, what, when, where Gantt chart? Follow Up Check results Make adjustments if necessary Standardize to insure continued results Stakeholder Signatures: PDSA A3 TEMPLATE

TAPP Algorithm TAPP in Back until only two rooms open per POD Front TAPP Rooms 10, 11, 12 Protocol/Assessment RN & Tech assigned 11a-3a No Dispo FT Waiting FT Room PNP Orders Yes Move to ED if needed Complete Orders PNP Reeval Discharge Greet RN Sort All Hem/Onc and neonate with fever to ED room/does not need to wait for MD/RN TAPP Protocols Initiated by primary RN Reception/S ort VS Tech ED Room Available yes TEAM Lead Matches RN, PMDC, RCP/MD resources and TAPP in ED room MD meets pt and staff member in ED room to TAPP MD completes H&P & verbalizes plan to clinical staff and family MD places orders in IBEX in room RN completes Initial Assessment, Med Rec and orders NO Patient to Central Wait Protocol/Assessment RN completes IA and protocols

Outcomes Key measures selected to track for the original project at Scottish Rite included: Overall Median ED LOS for discharged patients (daily and monthly) includes all patients from Greet (sign in) until they are removed from the tracking board (discharged) ED LWBS Rate (monthly) number of patients that arrive to the ED (sign in) but leave before they have received a medical screening ED Press Ganey Customer Service Scores (monthly) mean score and percentile ranking compared to other EDs in the Press Ganey database that see more than 40,000 patients/year Length of Stay Our Lean process improvements have decreased the overall median LOS for discharged patients in the SR ED by more than 12 percent since late fall 2008. Scottish Rite ED Median LOS for Patients Discharged Home Better Better Median LOS Control Limit Center Line Scottish Rite 2008 2009 2010 Median LOS (minutes) 126 114 111 79057 Volume (Discharged 69488 (includes H1N1 Patients) surge volume) 75891

Left Without Being Seen (LWBS) Although it was not part of our initial project aim, decreasing LOS has also led to a decrease in LWBS. Decreasing LWBS improves overall revenue, because it increases the number of billable patients who remain for treatment in the ED. Our LWBS rates are among the lowest in our national peer group (LWBS rate in 9/2009 was during H1N1 surge only reached 0.7% with >3,000 additional patients). Scottish Rite LWBS Better Mean LWBS Control Limit Center Line Scottish Rite 2008 2009 2010 % LWBS 0.4% 0.4% 0.2% Volume 284 325 180 Customer Service We relied heavily on our Press Ganey results to determine whether families were happier with the new process. The SR ED has received Press Ganey comments comparing the old process to the new, and indicating how much patients and families appreciate having a physician waiting when they are placed in a room: I love the fact that the doctors are already waiting when you get to your room it moves the process along much faster. We went right into the ER and the doctor was in the room within 5 minutes. Very streamlined process. The provider was waiting at the door when we arrive in rm. 32. Job well DONE.

The doctor came right in and treated my child immediately when we arrived in the room. Excellent doctor! He was in our room issuing directives before I could get my daughter in bed. The doctor was in the room as soon as we got in the room! We loved that we did not have to wait in the room long before the doctor came in. Doctor met us in the room as we were led into it. Wow! Before, the waiting time was pretty long. Now it is very short. That is impressive. I was so impressed with the service you usually spend basically all day in the emergency room and I was surprised that wasn't the case here. I was in and out, the staff was very helpful and efficient. Emergency Department Standard Press Ganey Questions Overall 2008 2009 2010 Sample Size 1233 1849 1479 Scottish Rite 88.6 89.0 90.4 Egleston 86.6 88.1 89.6 Hughes Spalding 87.2 Benchmark Mean 82.7 82.5 83.5 Fast Track After seeing the success of Lean in our main ED process improvement, we held an additional Kaizen event (Lean process activity) for our Scottish Rite campus Fast Track,

or urgent care. From 2008 through 2010, we decreased the overall mean TAT for Fast Track (FT) by 13 percent at Scottish Rite. Scottish Rite Fast Track Median LOS Median Total LOS) 120 110 100 90 80 70 2008 2009 2010 median = 89 median = 79 median = 77 Better 60 Better 50 Median LOS Control Limit Center Line 200803 200806 200809 200812 200903 200906 Period 200909 200912 201003 201006 201009 201012 Scottish Rite 2008 2009 2010 Median LOS (minutes) 89 79 77 Volume 23188 28528 26677 H1N1 Pandemic We were challenged in August/September 2009 with a very unusual surge in volume related to an H1N1 outbreak. We maintained our process, even when we were challenged to revert to our prior process. We were able to maintain our improved LOS, even with the addition of more than 3,000 patients seen in the Scottish Rite ED (see comparative graph for same timeframe 2008 vs. 2009).

Scottish Rite Mean Total LOS for All Patients Scottish Rite 2008 (8/20 9/22) 2009 Pandemic (8/20 9/22) Mean Total LOS 166 149 Volume 7027 10387

Innovations: Team Assessment Pull Process Not too many people will automatically make a connection between manufacturing automobiles and providing health care but they do have something in common: a value stream. For auto manufacturers, this involves all activities related to transforming raw materials into a finished product and delivering it to the customer, and in healthcare it concerns all activities related to providing care to a patient. As a result, it is not surprising that Children s Healthcare of Atlanta was able to use a process improvement strategy from the auto industry to improve efficiency in one of its emergency departments. Using Lean, a rapid process improvement philosophy derived from the Toyota Production System, the Children s Healthcare of Atlanta, Scottish Rite campus implemented a technique it named the Team Assessment Pull Process (TAPP). Emergency department (ED) staff chose the word pull because it captures the crux of the methodology: they take on work when they re ready for it, rather than having it pushed on them. Using TAPP, Scottish Rite was able to reduce the overall median length of stay (LOS) in the ED from 153 minutes to 125 minutes. Excluding fast track patients the median LOS in the ED decreased from 192 minutes to 167 minutes. TAPP has also allowed Scottish Rite s ED to reduce median door to provider time from 44 minutes to 28 minutes. Choosing Lean In 2007, Scottish Rite s ED was grappling with how to accommodate an increasing patient volume given space and resource constraints. They quickly discovered adding more space was not the answer. We pursued the traditional approach to reducing ED length of stay by increasing our ED capacity, notes Marianne Hatfield, system director of emergency services for Children s. We underwent an ED expansion that increased our capacity from 38 beds to 54 beds, but after the first year in our new facility, our ED LOS had actually increased, not decreased. Lean was attractive, she says, because it requires a brief but intense time commitment up to one week of consecutive full day meetings followed by rapid process implementation trials after the week of process re design. Lean also Copyright 2002 2011 Urgent Matters 1

places heavy emphasis on frontline staff involvement in process improvement, which appealed to us. We knew that the frontline staff would be experts in the in their current process, she says. After visiting Seattle in January, 2008 to observe how another hospital implemented Lean, Scottish Rite established a Lean team, comprised of frontline staff nurses, physicians, and ED technicians who undertook the process review and re design work. By mapping their processes, they were able to identify variation and waste. Waste was defined as any activity that was not seen as value added by a customer. In the ED, this included redundant processes and re work; searching for supplies needed for patient care; deciding which patient to see first when there are multiple sets of orders; interruptions in care; making a patient travel for a procedure; and any delays for any reason. Team Assessment Pull Process The team decided to focus on redesigning the flow for a segment of the ED visit with the most variation and waste. That one part, says Hatfield, was the initial nurse and physician assessment. Staff and physicians recognized there was a great deal of variation and waste in their assessment processes and particularly in terms of clinician coordination, Hatfield says. A patient could see a physician, nurse or technician in any order, and depending on whom the patient saw first, they could be in a room for an extended period of time without any treatment starting. Nurses assigned to more than one patient simultaneously would have to decide which set of physician orders to initiate first. Physicians were often frustrated because the orders were not completed in a timely manner. The waiting and delayed decision making equaled wasted time for patients, nurses and physicians. TAPP presented the most value added process for the patient, says Hatfield. Under this system, the patient is seen by the physician and nurse immediately after being placed in a room. The nurse completes the treatment plan ordered for the patient before being assigned to the next patient. Copyright 2002 2011 Urgent Matters 2

Patients are no longer put in rooms simply because one is available, says Hatfield. They are now pulled to a room only when a physician and nurse are both ready to start their treatment plan. TAPP has not only improved communication between physicians and nurses, it has improved the communication for the patient and their family members. The patient and his or her family are not asked redundant questions because the physician and the nurse complete the assessment together, Hatfield notes. The patient and family are able to hear the physician and nurses verbalize the plan of care. The 5 S s In order to further expend the benefits of TAPP the ED adopted the 5S system, which involves: Sort: Remove from workplace all items that are not needed for current operations and activities. Set In Order: Arrange items needed so they are easy to use, and label them so they are easy to find and store. Shine: Keep the workplace tidy, sweep floors, clean equipment, and generally make sure everything stays clean. Standardize: Adopt a method of working to ensure the first three pillars are maintained. Sustain: Ensure and make it a habit that everyone adopts and carries out correct procedures. We used 5S to standardize the supplies in our patient treatment rooms, both in the cabinets and at the head of the bed, says Hatfield. Staff members and physicians provided input into what they needed the most when treating patients and we organized supplies to be accessible and useful. There are visual cues, such as lines and labels that indicate the par level and when a supply needs to be restocked. Clinician Involvement Leads to Clinician Buy In Lean is completely customer focused, and we have seen an increase in our overall customer satisfaction scores as a result, Hatfield says, adding that the Press Ganey scores for the ED have been in the 99th percentile ranking for overall rating of care for seven out of eight consecutive quarters. Copyright 2002 2011 Urgent Matters 3

Process change is not easy, Hatfield says. People are naturally resistant to change because they have become adept at doing their work in a certain way and often fear they will not be as successful if they have to change their practice or process. The process change implementation was not initially embraced by all of the staff and physicians, and there was a period of resistance that required focused communication, re education and commitment on the part of the Lean team. We were successful, because we had physician support and several physicians on our Lean Rapid Process Improvement Workshop (RPIW) team. Our partners in our physician group understood the patient is there to see them, and they wanted to improve the visit and decrease the LOS for the patient. A take away lesson, says Hatfield, is the importance of senior leadership of the hospital campus to serve as a supportive sounding board without participating directly in the RPIW. As the Director of ED operations, I sat in on the RPIW, but I did not have a voting voice in any of the decisions the team made, she says. My role was to help them to procure any needed supplies, resources or staffing changes that might need to occur based on their process change recommendations. While it was initially difficult for me to remain passive and not make recommendations, I soon became enthralled with the ideas and recommendations provided by the participating frontline staff and physicians, and I am still amazed at the major process change that they have successfully implemented. Marianne Hatfield, RN, BSN, CENP, System Director of Emergency Services, Children s Healthcare of Atlanta Copyright 2002 2011 Urgent Matters 4