CHANGING PATIENT AND WORKFLOW PARADIGMS AT HOSPITAL DE LA CONCEPCIÓN EMERGENCY DEPARTMENT

Society for Healthcare Systems SHS 2006

Noris Torres Santiago, MSIE, PEHealth Systems Engineering DivisionCIRACET Corp

Hospital De La Concepción

l 167 Licensed beds

l 750 admissions per month

Emergency Department

l Fast Track and Observation Area

l 3,105 ED visits per month

l 80% of the ED visits go through the “Fast Track Service”

l 70% of the hospital admissions originate at the ED

l 20% of the ED visits are admitted

The problem:The effect

Reduction ofPersonnel Satisfaction

Unsatisfactorytime from arrival

to MD Eval

UnsatisfactoryLOS

Reduction ofPatient

Satisfaction

The approach:Lean Six Sigma

Lean Six Sigma

DelightCustomers

ImproveProcesses

Qua

lity

Spe

ed

Var

iati

on&

Def

ects

Pro

cess

Flo

wData and Facts

TeamWork

Reference: What is Lean Six Sigma? By: M. George, D. Rowlands, and B. Kastle

Voice of the Customer toCritical to Quality (CTQs)

l What are the customers needs andexpectations?

l Arrival to MD Evaluation = 40 minl LOS = 4.0 hours

Value Stream Mapping

Flow Chart of ED Process

Actual Layout

STAI

R-1

VENDING MACHINE AREA

TOILET TOILET

FAST TRACK

STAFF LOUNGE ADMITING AREA

NURSES SUP.MALES

STAFF LOCK

BATH RM BATH RM

PROCESSING AREA

EMERGENCY DEPARTMENT

SERVICESCUSTOMER

RMBEREAVEMENT

MEDICAL DIRECTOR

SEC.

CODE RM X -RAY

CA1

CA2

OBGYNTRAUMA ROOM

STATIONNURSE

MEDPREP

CONSULTING

PARKEQUIP

O2

ISOLATION

OFFICE

TOILET

TOILET

CA3

O1 ISOLATION

FEMALES STAFF LOCK

Triage

Financial Record

Nurses

Exam Room 1&2

IV and Respiratory Treatment Room

Exam Room 3&4

Waiting Room

Patient Flow Paradigms

l Fast Track is only a name

l Fast Track is Medical Evaluation

l Patient goes to the waiting room after eachstep in the process.

Patient Flow Paradigms

l 2 MDs at the “Fast Track Area” evaluates 87.2% of the ED visits.

l 1 MD at the Observation Area only evaluates 12.8% of the ED visits.

l Serial Processes

l Patient can not be seen by the doctor if Financial Registration is not completed (unless is an emergency).

EFFECT: UNBALANCED WORKLOAD

Patient Flow Paradigms

l IV and Respiratory Therapy Room (Fast Track Treatment Room) is far away from the nurses station.

Let’s measure

Average Visits per shift

39.537.3

12.5

0

5

10

15

20

25

30

35

40

Shift

7 to 3

3 to 11

11 to 7

Average Visits by day of the week

75

80

85

90

95

100

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Valley

PeakPeak

Average visits per hour

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

12 A

M1

AM

2 A

M3

AM4

AM

5 A

M6

AM7

AM8

AM

9 A

M

10 A

M

11 A

M12

PM

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 P

M

11 P

M

Hour

Pat

ien

ts p

er H

our Peaks

Valley

Laboratories and X-Rays

l Laboratories are performed to more than85% of the patients.

l X-Rays are performed to 20% of the patients.

Measure

Six Sigma

Let’s measure variability!

Process Capability

l Provides management with a single number to assess the performance of a process or its improvement over time.

l Cp, P, Cpk

l Process Sigma

Process Sigma

LSL USL

The area under the curve between the LSL and USL is expressed as the yield.

Process Sigma Calculation

15.9%841,3450.5

30.9%691,4621

42.1%579,2601.3

46.0%539,8281.4

69.1%308,5382

93.3%66,8073

99.38%6,2104

99.977%2335

99.99966%3.46

YieldDPMOSigma

Arrival to MD

Business Goal = 0.5 hrs

The processTime from Arrival to MD Evaluation

Average = 1.24 Average = 1.24 hrshrsSD = 0.67SD = 0.67N = 411N = 411

TriageFinancialRecord

Physician Evaluation

Control Chart for Time from Arrival to MD

Observation

Ind

ivid

ua

l V

alu

e

41137032928824720616512483421

3.0

2.5

2.0

1.5

1.0

0.5

0.0

-0.5

_X=1.236

UCL=2.882

LCL=-0.409

111

I Chart of Arrival to MD

Process Capability Analysis for the Time from Arrival to MD Evaluation

1.60.80.0-0.8-1.6-2.4

LSL* USL*

transformed dataProcess Data

Sample N 411

StDev 0.665895Shape1 2.37362

Shape2 1.69675

Location -0.284501

LSL

Scale 7.19549

A fter Transformation

LSL* -3.03922Target* *

USL* -1.19077

Sample Mean*

0

-0.0212643

StDev * 0.994753

Target *

USL 0.5

Sample Mean 1.2363

O v erall C apabilityPp 0.31

PPL 1.01

PPU -0.39

Ppk -0.39

O bserv ed PerformancePPM < LSL 0

PPM > USL 875912

PPM Total 875912

Exp. O v erall PerformancePPM < LSL 1207

PPM > USL 880137

PPM Total 881345

Process Capability of Arrival to MDJohnson Transformation with SB Distribution Type2.374 + 1.697 * Log( ( X + 0.285 ) / ( 6.911 - X ) )

Length of Stay

Transfers to another institution, ER to OR, ER to OBGyn, and LAMA were not considered.

Business Goal = 3.0 hrs

The processLength of Stay

Average = 4.93 Average = 4.93 hrshrsSD = 2.92SD = 2.92N = 469N = 469

TriageFinancialRecord

Physician Evaluation

Treatment Discharge

Process Sigma Analysis for Fast Track Area LOS

In

div

idu

al V

alu

e

19117215313411596775839201

10

5

0

_X=4.22

UCL=9.63

LCL=-1.19

Mo

vin

g R

an

ge

19117215313411596775839201

8

4

0

__MR=2.035

UCL=6.647

LCL=0

Observation

Va

lue

s

190185180175170

10

5

0

9.07.56.04.53.01.50.0

LSL USL

Specifications

LSL 0.5

USL 4.0

12840

Within

O v erall

Specs

Within

StDev 1.80368

C p 0.32

C pk -0.04

O v erall

StDev 2.02305

Pp 0.29

Ppk -0.04

C pm *

11

11

1

1

Process Capability Sixpack of FT LOS

I Chart

Moving Range Chart

Last 25 Observations

Capability Histogram

Normal Prob PlotA D: 0.858, P: 0.027

Capability Plot

Process Sigma Calculation for Fast Track Area LOS

1.46SigmaProcess =

Measure

Lean

Let’s measure how fast is the process!

Value Stream Mapping

Capacity Analysis for the Fast Track Area (For 7 to 3 and 3 to 11 shifts)

3.3 (5.0)7.515.08.1Patients per hour

14.7 (9.8)5.23.06.0Cycle Time

2 (3)221Resources

26.5 (39.8)6012065Patients per shift

29.410.56.06.0Process Time

NurseMDFRTriage(Time in min)

Average Demand: 39 patientsMaximum Demand: 59 patients

You are only as strong as your constraint

Treatment: Nurses

3.3 patients per hour26.5 patients per shift

Process Cycle Efficiency (PCE)

l PCE is an expression of the portion of value added work within the cycle time.

l Average PCE = 10%

l Lean Goal = 25%

14.08.295

89.42===

åtimetotal

timesservicePCE

Patients Left Prior to each step of the process at the Fast Track Area

2Re-Evaluation

16At the Observation Area

3On-Treatment

(waiting for results)

6Treatment

2Physician Evaluation

2Financial Record

1Triage

QuantityPatients left prior to

Analyze

Wastes in the system

l Waiting time

l Transportation

l Processing

l Motion

l Defects

Changes

l A New Layout and Pneumatic system for the Fast Track Area.

l Change the workflow.

l Clerk for the Fast Track Area.

l Bedside Registration.

l Triage classification and processes

Triage MD Eval.

Changes

l Laboratoryl One Phlebotomist was hired for the 3 to 11 shift

l X-Rayl X-Ray Room at the ER

l Admissions Departmentl Coordinator at the ED

l More communication

Pick Chart

Implement Possible

Challenge Kill

• Work Balance• Disposition placed by RN• More lab resources• Admission coordinator

in ED

• HIS access to the host• Bedside registration

• Layout• Relocate pneumatic tube

BIG Payoff SMALL Payoff

EASYto implement

HARDto implement

DATA

ENTRY

ELECTRICAL KM

STO.

EKG.EXAM. KM

STAI

R-1

VENDING MACHINE AREA

TOILET

NURSES SUP.

TOILET

TOILET

StretchersAnd

Wheelchairs

OFFICE

Triage Exam Room

1

Exam Room

2

Exam Room

3

Exam Room

4

Fin Reg

Fast Track

Layout Alternative 1

Proposed Work Flow

Results

4.94.6

4.2 4.13.9 3.9

3.0

1.2 1.2 1.2 1.1 1.00.8

0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

July August October GOAL

Questions and Answers

CIRACET CorpPO Box 8970Ponce, PR 00732

www.ciracet.com

torresn@ciracet.com

Thanks to SHS and Thanks to SHS and to the audience!to the audience!