Lean-driven improvements eliminate waste, boost patient satisfaction in a matter of weeks
Administrators credit front-line staff participation, top-level support for success
With anemic demand for emergency services and suboptimal patient satisfaction scores, administrators at North Adams Regional Hospital in North Adams, MA, knew they needed to do something to change the status quo. "The region we are in is shrinking in population, but the population is aging so we should have been seeing about a wash where [the volume of] ED visits was about the same," explains Brent Drennan, MBA, the director of lean transformation at the hospital. "The aging should have offset the population decline, but we were actually seeing shrinking ED visits."
To address the problem, Drennan, whose background is in manufacturing, assembled a team consisting of representatives from all the key service areas that impact ED operations, ranging from clinical and administrative functions to housekeeping and patient relations. In August of this year, the team huddled, putting the hospital’s ED processes under a microscope to figure out what could be done to improve efficiency as well as the patient experience.
Participants in this process admit they were surprised at all the built-in delays patients encountered when seeking emergency care. But perhaps most surprising was the speed with which team-driven improvements were able to be implemented. Within six weeks of the original team meeting — referred to in lean parlance as a kaizen event — average wait times in the ED were down to six minutes, less than half what they were before the improvement process. And average door-to-physician times stood at 19 minutes, a reduction of eight minutes from the ED’s performance in July.
Now, a few months into the improvement effort, it’s clear that the approach is driving continued progress. Volume in the ED is on the upswing with average visits per day increasing from 42 to 54, the hospital’s left-without-being-seen rate — which was hovering at 1 to 2 patients per day before the improvement process was implemented — is now close to zero, and the ED’s standing in terms of patient satisfaction on Press Ganey surveys is at the 96th percentile, a jump of more than 25 points since the improvement process began. (Also see: "Management Tip: When implementing lean-driven solutions, have a plan in place for staff communication," p. 139)
Team members acknowledge that even that before the kaizen event, they understood that wait times were a problem, but they didn’t realize just how cumbersome the process of seeking emergency care was for patients. "We weren’t aware of how many steps there were in the process or of all the built-in delays [that would occur] in getting the patient from the front door to the treatment room," explains John Aufdengarten, RN, MSN, MBA, the interim director of the ED. "We were surprised at how many hard stops there were."
For example, there were more than 50 questions and 50 fields that needed to be filled in during the triage process, notes Aufdengarten, so this was an area that team members quickly targeted for an overhaul. To streamline the process, team members designed a three-stage triage approach that is focused on getting patients back into a treatment room quickly.
"The first part is what we are calling 15-second triage. This is what the charge nurse does in the triage room right before she walks the patient to a [treatment] room," explains Cheryl Ericson, RN, the ED nurse representative on the improvement team. The nurse will ask the patient what he or she is there for, and then based on this information, as well as a quick assessment of how the patient appears to be doing in terms of color and other immediate indicators, the nurse will either walk the patient to a treatment room or take the patient there by wheelchair, she explains. "This is a big change, in that before [the new process was implemented] we would stop in the triage room, sit down for five to 10 minutes and assess why the patient was there, and get their medical history and vital signs before transporting them to a treatment room," adds Ericson.
During the second stage of triage, called quick triage, either the charge nurse or a nurse who is assigned to the room will retrieve what they consider to be critical information for the physician such as vital signs, allergies, and other aspects of the patient’s medical history," explains Ericson. "They are able to get [this information] right to the doctor, especially if the doctor is waiting to see the patient," she says.
The third stage of triage, called data triage, involves retrieving all the information that wasn’t necessarily critical for the physician to have right when he or she walked into the room, explains Ericson. For example, information about a patient’s smoking or social history would typically be retrieved on the back end of the quick triage stage, or at some later point during the visit if the physician is waiting to see the patient.
"We have tried to make this as dynamic as possible so that when the patient is being walked to a room, triage continues," explains Fernando Ponce, MD, an ED physician who served on the lean improvement team. "The doctor also tries to be part of it by going into the room as soon as the patient arrives. Both the doctor and the nurse who are going to be taking over the patient continue the patient questioning in order to minimize having to go over [the same] questions again and again."
In addition to streamlining the triage process, team members also decided to divide the ED into different sections that correlate with nursing assignments. "We have 14 rooms, and now we have pods where a nurse is responsible for three or four contiguous rooms," explains Ericson. "Before [this change], a nurse might have a room on one end of the ED and another patient in a room on the other end."
With the old approach, nurses tended to feel isolated, and they were less informed about what was happening in adjacent rooms. "[Consequently], they were less likely to help another nurse who might need an extra pair of hands because they didn’t really know what was going on," observes Ericson.
The physicians struggled with the old system as well, reporting that it was difficult to find a nurse when staffers were randomly assigned all over the department. "The pod assignments saved a lot of steps for the nurses and saved a lot of steps for the physicians as well," says Aufdengarten.
Further, where the ED used to have rooms that were specified for particular types of problems, the team members decided to change the system so that almost any patient can now be brought to any room, notes Ericson. "I think, with time, people are starting to realize to some degree that the way we always did things doesn’t have to be the way we always do them," she says. "But it has taken time."
Ponce agrees, but despite some initial resistance to the process changes, he sees clear evidence of improved efficiency in the department, including lower noise levels and enhanced cooperation. "It is more of a team effort from all areas," he says. "I am less tired by having less wasted motion during my shift. Similarly, I can say that when this works smoothly, there is a sense from the nurses with whom I am working that they [feel] they are taking care of the patients in a more satisfactory fashion rather than feeling that they are rushed to do things at a time when mistakes could be made and safety could be compromised."
Refine improvement process
While refinements continue on the front end of the process, administrators are now also applying the lean approach to other areas that need work. For example, Drennan observes that while the ED has a good process in place for handling expected volume, an improvement team has now been tasked with developing a better approach for handling unexpected patient surges. "The other day, by 7 a.m. all of our rooms were full. And it was on a day in the middle of the week when there is normally low volume, so we weren’t staffed for that," he says. "We don’t have a method to allow us to bring in additional staffing or to respond quickly to that sort of a spike, so that will definitely be [the target] of one of our next [kaizen] events. And we have found that this is not just a problem in the ED, but throughout the hospital."
Another issue affecting the ED but requiring hospital-wide attention is a painfully slow process for admitting patients to the hospital from the ED. Drennan has already staged a second kaizen event to identify opportunities to improve this process. "We were trying to figure out how to get patients from the ED up to the inpatient units faster, so that was one side of the equation because we were focusing a lot on the ED," he explains. "But the other side of the equation was nurses on the inpatient units who were frustrated with how laborious the inpatient process was themselves, so we actually came at it from two different sides."
It is too early to report outcomes from this program, but Drennan notes that early indications are that the improvement team members involved with this process will be able to deliver the same types of gains as the earlier effort. Further, the more hospital administrators and staff work with lean-driven methods, they are becoming more adept at using the process, he adds.
Be inclusive, narrow focus
For example, one of the lessons learned from the first effort is that it is important to insure that there is strong staff nurse representation on the improvement team. Aufdengarten praises the contributions of Ericson, who served as the sole staff nurse on the first improvement team, but he suggests that she would have had an easier job selling the proposed changes to her colleagues if more of them had been included on the team. "She did a spectacular job of communicating with the nurses in the department, but there would have been a multiplier effect [if she had had help from other nurses]," he says.
Drennan agrees with this point. "If we had had another nurse or two on the team, I don’t know that we would have necessarily come up with a different plan, but I think that it would have been easier for the nursing staff to accept the changes," he says.
Nonetheless, participating in the process had a motivating influence on Ericson. "You sort of own it, so you become part of it," she says. "I do believe that the more staff you have involved, the more they will buy in, and the more they will get behind it."
Aufdengarten advises colleagues interested in using a similar process to drive improvement to narrow their focus to one area to start. "We didn’t look at throughput or the outcomes part because you can’t address it all at one time," he says. "But you will become more aware of the barriers to change [in your organization], whether they are [related to] equipment, processes, or people."
A primary key to eventual success is support from the organization’s leaders, stresses Drennan. "If the top person doesn’t buy into it, the effort will falter," he says, noting that hospital executives at North Adams made it clear to all staff that change was coming, and that they needed to adapt or leave. "That was a tough message for some people to receive, but it was received."
- John Aufdengarten, RN, MSN, MBA, Interim Director, Emergency Department, North Adams Regional Hospital, North Adams, MA. E-mail: firstname.lastname@example.org.
- Brent Drennan, MBA, Director, Lean Transformation, North Adams Regional Hospital, North Adams, MA. E-mail: email@example.com.
- Cheryl Ericson, RN, Nurse, Emergency Department, North Adams Regional Hospital, North Adams, MA. E-mail: firstname.lastname@example.org.
- Fernando Ponce, MD, Physician, Emergency Department, North Adams Regional Hospital, North Adams, MA. E-mail: email@example.com.
When implementing lean-driven solutions, have a plan in place for staff communication
Hospitals employing lean techniques for process improvement often use "kaizen" events, where front-line personnel get together and identify wasteful practices or other problems, and then devise proposed solutions. However, key to making any changes stick is a good mechanism for communication and enforcement of these changes to the rest of the staff, according to Brent Drennan, MBA, the director of lean transformation at North Adams Regional Hospital in North Adams, MA.
Drennan advises that the way a lean improvement team at his hospital communicated changes to the ED’s triage process that were devised during a kaizen event was by having a staff nurse who participated in the event take charge of making sure her colleagues were thoroughly apprised of what was expected of them when the changes went live. "She worked the first day of the experiment, not as a nurse but as a coach for the charge nurse and the pod nurses to get them through this," he explains. "She came in and worked with every shift and communicated the message to them over several days."
A similar approach was employed with the physicians, says Drennan, and the changes have now become part of the ED’s standard operating procedures.