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ED's turnaround time cut by almost 30 minutes
Process 'pulls' patients out of waiting area
By implementing a Lean process change that it calls TAPP (Team Assessment Pull Process), the ED leadership in the Children's Healthcare of Atlanta system has realized a 25-minute reduction in median overall turnaround time, from 192 minutes to 167 minutes, excluding its fast track. The ED also achieved a 16-minute median improvement in door-to-provider time, from 44 minutes to 28 minutes, at its Scottish Rite campus. In addition, median length of stay has dropped from 136.5 minutes to 122 minutes.
TAPP works like this: The patients are greeted in the waiting room by a patient access greeter. A registered nurse is sitting next to the greeter from 9 a.m. to 3 a.m. They are then assigned an acuity level by the triage nurse. "From there, they show up on our [ED automation software program] board as a patient in the waiting room," explains Cresta Pollard, RN, BSN, assistant nurse manager. "Then, when a doctor is ready for a patient, they put their name as well as their communication number on the board."
The nurse will do the same, she explains. Once a second team member has signed up, they will call the first via the facility's internal phone system (ASCOM) and say he or she is ready for the patient. The nurse or a tech then will get the patient and tell the doctor what room they are going to. The doctor will meet the nurse in the room, where they will obtain a history, conduct a physical exam, and communicate the plan of care. The nurse will carry out the orders.
Before this change, the work in the ED had been "scattered and frantic," says Pollard. "We would have three to four patients at a time and put them into rooms, but they could be waiting an hour or more for a doctor; you might have orders on all four working at the same time, start with one patient, then go to another, and by the time you got to the last one, it could be an hour before it was all done."
Jennifer Berdis, RN, BSN, manager of clinical operations, says, "The nurses actually had to make decisions about what patient was a priority, while every doctor felt their patient was a priority, so the nurse was stuck in the middle. Now they do not have to make that decision because they are only working with one patient until they are done with orders."
The "pull process" refers to the fact that each patient is pulled by the nurse into the pod, or treatment area, where they meet their team. There are three pods in the department (including fast track), each with 17 rooms. The number of pods that are open and the number of team members varies according to the census. At full census (3 p.m.), there are approximately six nurses and three physicians per pod.
James Beiter, MD, the medical director, says, "The intention was to have the physicians stay within a team and a pod, but because we will open and close certain areas in the ED, it's hard to keep us in one area; we go where help is needed. It has not been as strict as it has with the nurses."
For more information on pulling patients out of the waiting room, contact:
ED team goes 'back to school'
Before it could successfully implement a Lean process change that it calls TAPP (Team Assessment Pull Process), the ED leadership in the Children's Healthcare of Atlanta system had to be educated in the process. The need for this education was clear, recalls Marianne Hatfield, RN, BSN, CENP, system director of emergency services.
"We had actually moved into a new facility and increased our capacity by one-third without improvement in our turnaround time, so we knew we had to look at our processes," Hatfield says.
They had used a Six Sigma approach in previous years and had found it to be a little slow, says Jeff Rehberg, BIE, ME, senior quality consultant, "So, in early 2008, we approached Georgia Tech to learn more about their lean methodology because we had heard good things about it," he says.
A team of 18 from the system attended the class at the Georgia Tech Innovation Institute and then spent three days with Tech representatives on site doing mapping, observations, collecting quick data, and doing some trials and tests on TAPP, which they had studied at the institute. "Then they backed out and let us move forward. I went to Lean Champion training [advanced training provided by Georgia Tech] and pulled that exercise into the children's ED and other hospital units, and I continue offer a one-day class to the ED and house staff," Rehberg notes.
Part of the philosophy in Lean is the elimination of waste, Hatfield says. "Our 'waste' was searching for doctors, deciding on which patients took priority, and having more than one person do the same thing," she says. By pairing nurses and doctors into teams, she says, "We improved communications for the team and streamlined visits for the patients."
Rehberg says, "The whole concept of 'pull' is that you take on work when you're ready for work rather than having it pushed on you. This evens out work for the nurses."
The Five S's helps improve efficiency
The ED management team at Children's Healthcare of Atlanta system has used several valuable Lean tools to implement successful process changes that have streamlined work flow. One of the most effective is an approach called Five S's. Its five pillars are:
"It's really a way of organizing all supplies and equipment as efficiently as possible, and having them in an appropriate place," explains Jeff Rehberg, BIE, ME, senior quality consultant. "We basically took one patient room and asked ourselves what we needed and how could best organize it, then replicated it throughout the rest of the ED."
As a result, when a staff member enters any patient room in the ED, "they should be able to find almost anything they need blindfolded," he says.
Jennifer Berdis, RN, BSN, manager of clinical operations, says, "So, for example, the left-hand side of the bed is for the caregiver, so the monitor is there, and under the monitor is a basket with a pulse oximeter and electrodes, and under that is a bin to house air curettes, gauze, bandages, and things we most frequently need. It allows you to take fewer steps within the room itself in order to complete an exam."