After a move, ED patient satisfaction and throughput measures "tanked" at Sharp Memorial Hospital in San Diego. By eliminating duplication, leaders not only improved operational efficiency, but patient experience as well.
This article appears in the July/August issue of HealthLeaders magazine.
When Sharp Memorial Hospital moved into its new patient care tower in 2009, the emergency department team expected better patient flow and, as a result, improved patient satisfaction to come along with the new facility. It didn't happen.
"We had a beautiful space, but we brought ineffective and cumbersome processes into the new building that really were not optimal for our patients," says Susan Stone, senior vice president and CEO of Sharp Coronado Hospital and Healthcare Center, who at the time was chief operating officer and chief nursing officer at Sharp Memorial in San Diego. "It was one of those examples where we thought going into a new space would fix the problems and it didn't."
For an organization that prides itself on being patient-centered, and that only two years previously had been awarded the Malcolm Baldrige National Quality Award, having ED patient satisfaction and throughput measures "tank," as one team member described it, got everyone's attention. Rather than try to tweak the process, Stone and the hospital leadership team decided to evaluate the ED from top to bottom.
"The first thing that we did was to observe and do a lot of data collection about the patient experience overall," Stone says. "And then when we met together to prioritize, we decided to come at this project from the patient's lens rather than my perceptions as a CNO or my team's perspective as healthcare providers."
Sharp's Lean Six Sigma team was brought in to "look at the whole process from the time an emergency patient presents all the way to head in bed upstairs," says Kurt Hanft, Lean Six Sigma Master Black Belt.
But Hanft and the team recommended that rather than just do a Kaizen event—designed to address a particular issue over the course of a week—the ED team at Sharp needed to "create a department of problem solvers," Hanft says. "And that is not something that you just do overnight. You need executive involvement and a lot of training at the staff level so they can be a part of it because it's really about frontline engagement."
A value stream map—a Lean process of analyzing the flow required to bring a service to the consumer—resulted in some shocking data: 82% of the patient's time was wasted in waiting and assorted delays.
"Our goal was to eliminate all the delay and waiting from the patient experience so that we were optimizing their time for every moment they were with us," Stone says.
The waste began with an all-too-familiar triage process where the patient was often telling his or her story "up to four and five times," Stone says. The flow was typical: Talk to admitting nurse. Go back and sit down in waiting room. Talk to triage nurse. Go back and sit down in waiting room. Triage nurse again. More waiting. Then back to a bed in the ED to explain all over again to the ED nurse. Stone says the team realized it already had a model of sorts for how ED patients should be treated.
"We looked for examples of when we were best meeting the patient needs," Stone says. "And we found the experience of an active chest pain patient: The patient arrives. The patient's immediately taken to a bed in the ED. All the team members gather around, listening to this story. Everybody's working shoulder to shoulder getting everything done and expediting the patient care. So what we did was try to use that model for every single patient who arrives to the ED."
With the model determined, the next step was "to adopt the philosophy that triage is not a location, it's a function," Stone says. "The philosophy became that patients presented and they were taken to a bed."
A change in philosophy meant a change in workflow. Some hospitals across the nation are adopting an ED "ambassador," a nonclinical role to greet patients and get basic information, and also supplementing physicians with midlevel providers to take simple cases. But Sharp decided to continue with the same staff mix.
"We don't use nurse practitioners," says Christopher Walker, MS, RN, NP, CNS, director of emergency services at Sharp Memorial Hospital. "We're a physician-only model. We contract with a physician group and they chose no midlevel providers. When you walk in the door, you are walking in to talk to a nurse, not an ambassador. It is a specially trained ER triage nurse. They are taking that basic registration information, but they're also already making that first-level assessment that's at a higher level than any ambassador could."
Triage assessment used to be for determining which patients had the highest acuity and needed to get back to an ED bed. Under the new system, ED acuity assessment only has the goal of getting to patients in the quickest way, Stone says.
"Triage assessment helps us assess what the needs are of the patient and to expedite the care each hour as opposed to determining who should be seen next from the lounge," Stone says. "Everybody's coming into a room. If they have a lower acuity, it just means that our goal is to get them out faster."
One of the overall goals of the redesign project was to decrease length of stay to fewer than three hours in the ED. Tactically that means the ED staff had to refocus on freeing up beds, which changed the way they viewed triage, Stone says.
"If there is a patient with a low acuity, that gives the team an opportunity to say, 'We can get this patient out in less than two hours.' So then there will be an open bed and the next patient does not have to wait. It became a different philosophy about how you use those triage assignments. They're an important function of the ED and we still use them, it's just not to prioritize who's sitting in the waiting room and who's not."
This story is drawn from an HLM Live event that took place on August 20th.
Reprint HLR070813-11
This article appears in the July/August issue of HealthLeaders magazine.
Jim Molpus is the director of the HealthLeaders Exchange.