Blog Posts


Implementing Lean Processes in the ED Improves Metrics

Posted on Wed, Oct 19, 2016
Implementing Lean Processes in the ED Improves Metrics

By Christine Kelly, RN, MBA, FACHE; Amanda Maxim, RN, BSN, MBA; Jan Beck, RN, BSN; and Shayne Middleton, RN, BSN, CEN

Nowhere is a glitch in the patient experience more pronounced than in the emergency department (ED). The ED team's ability to provide fast, efficient, quality care has a signifcant impact on each patient’s perception of care and the management of life-threatening injuries.

The processes in use today to manage patient flow from arrival to treatment to disposition are widely seen as inefficient and cumbersome. These inefficiencies often lead to long wait times and a lack of attention to patient needs and, potentially, prevent needed access to care. Recent publicity surrounding patients leaving without treatment, deaths in waiting rooms and overcrowding has become a catalyst for change in the industry. As a result, we are seeing a significant increase in the use of lean at hospitals nationwide.

It’s important to understand that achieving lean in the ED may rely heavily on improving processes in other departments. Lean can be most effective for improving patient throughput, but this means looking at the ED as one part of the delicate ecosystem of hospital care. While lean implementation may start in the ED, to be most effective it needs to extend through all patient flow paths.

When lean is applied to the front-end processes, patients can be seen more quickly. Lean in radiology and ancillary services also can facilitate patient treatment and diagnoses more quickly. Extending lean into the inpatient setting helps cut unnecessary hours off of the length of stay, which opens inpatient beds for new patients to be transferred from the ED. Lean for the OR helps ensure efficient operation of surgical services, allowing accommodation of emergency cases. Lean methodology works best when it encompasses the entire path of patient care.

Implementing Lean in the ED

A lean consultant was asked to conduct an emergency department lean rapid redesign workshop with the goal of improving operational efficiency.

Patients were experiencing an increased length of stay due to delayed diagnostics. Further, without use of pre-emptive orders at triage, it was taking 35 minutes from arrival to order entry by a primary care nurse if immediate bedding took place (and longer if no beds were available).

  • Patient presents to triage = 30 minutes; to room 110 minutes, wait for provider 60 minutes, Medical Screening Exam = 10 minutes, 5 minutes to order entry = total of 215 minutes from door to order entry
  • Provider order entry was 74 minutes from arrival
  • With pre-emptive ordering at triage, 24 minutes to order entry
  • LWOTs were two times the national best practice of 2.0 percent
  • Decreased efficiency ancillary services secondary to wasted time/trips to the ED

Contributing conditions:

  • No prioritization of services ordered – X-ray may collect the patient prior to lab draw, resulting in delay in results due to collection time
  • Transport of lab specimen delayed, placed in box on counter
  • No communication between ancillary departments
  • Pre-emptive orders not consistently used by nursing
  • Inconsistent "pull ‘til full"
  • Some physicians delaying medical screening exam on low-acuity patients, some saving for advanced practice providers

The Lean Solution

The consultant worked with the hospital’s nurse leaders to reach the following goals:

  • Implement bedside triage and registration process 100% of time, with “Pull ‘til Full” concepts (Patient-Centric Care) implemented across all shifts/staff
    • Minimize redundancy
    • Standardize triage process
    • Target arrival to provider time: 40 minutes
    • Bed to provider time: 25 minutes
  • Create more organized patient flow with space for simultaneous processes to take place, eliminating wait time and redundancy
    • Adequate resources in the right place
    • Keep vertical patients vertical and give the beds to the sick
    • Use discharge sub-waiting area
  • Consider plant flow redesign with existing spaces to include reassignment of current rooms for more efficient flow
    • Use of triage preemptive protocols 70 percent of the time
    • Improved ancillary communication
    • Collection to receipt of specimen to take only 5 minutes 90 percent of the time
    • Door-to-doc time to meet 40-minute benchmark
  • Educate ED, evaluate cost and benefits, recognize waste, plan-do-study-act, gemba walks
    • Reinforce "pull ‘til full" policy with 100% use of bedside computers
    • Educate nurses/providers in use of pre-emptive protocols
    • Flag on specimen box as visual cue for specimen awaiting transport, ED to assist
    • Lab access to private tracker board to allow comments
    • Lab to notify nursing when draw complete so tracker can be updated for X-Ray
    • Educate Radiology staff on use of tracker notifications
    • Metric comparisons

After implementation, the team’s results included:

  • Streamlined patient flow
  • Decreased throughput time
  • Decreased left without being seen (LWBS) rate
  • Improved patient and employee satisfaction
  • Improved quality in delivery of care
  • Reduced financial losses

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

This case study is one of many included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about this case study and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

Christine Kelly, RN, MBA, FACHE, is Vice President of Clinical Services for EmCare. Amanda Maxim, RN, BSN, MBA, is Vice President of Clinical Quality for Valesco Physician Services, Inc. Jan Beck, RN, BSN, is a Director of Clinical Services for EmCare. Shayne Middleton, RN, BSN, CEN, is a Divisional Director of Clinical Services for EmCare.


How to Get the Most Out of Data

Posted on Tue, Oct 27, 2015
How to Get the Most Out of Data

We recently interviewed Paul Silka, MD, Chief Executive Officer of EmCare’s West Division, and Jennifer McCullough, Senior Clinical Data Analyst for the West Division, about collecting, analyzing, and, most importantly, using data to improve care.
Q. With responsibility for one of the largest divisions in EmCare, how do you determine where to focus your efforts to make the biggest impact?

Whether you’re running a single department or a 20-state enterprise, metrics only matter if you can and will do something with the information. We have three rules that help us successfully manage metrics in a way that improves performance:

  1. Focus on fewer metrics. While there are many opinions about the optimal span of control for managing people, the number 5 is still very popular. We apply the same expectations for managing metrics. Pick five metric-based issues to which you can devote the appropriate time, energy and resources to make a difference. (View Source)
  2. Focus on the metrics that are within your control. In EmCare’s case, since we staff and manage physician groups in the emergency department, inpatient units and anesthesia, we focus on metrics that these physicians can control.

    It’s important to understand the difference between “influence” and “control,” and to devote resources accordingly. For example, in the ED setting, most organizations measure the time from the patient’s arrival to the time the patient is seen by the provider (arrival-to-provider times). While the experience may be seamless to the patient, for purposes of measuring in a way that can enact change, it makes more sense to break this measure into two distinct parts, arrival-to-bed and bed-to-provider. Physicians have more control over the bed-to-provider segment; if you try to hold them accountable for the entire arrival-to-provider process, you can cause frustration and disengagement.

  3. Prioritize the measures that matter. Healthcare systems often seek to measure a plethora of metrics. One benefit of working with an organization with a national view of healthcare measures is its expertise directing and educating teams on how to focus on the metrics that have the most impact on performance and patient care. When you are deeply entrenched in a process, it’s difficult to recognize that there may be more value in doing it a different way.

    At EmCare, we use our data as well as national sources to identify industry standards and best practices. Sources such as EDBA provide guidelines and national benchmarks. CMS quality measures are increasingly important to hospitals. Ultimately, the goals and measures are site-dependent; measurements are not uniform throughout the county.

Q. Are dashboards necessary?
Every time we circulate a dashboard, it’s as if we are saying “all hail the mighty dashboard, the savior of patient care.” That’s just not the case. The dashboard is not the only indicator nor is it even the most important indicator of patient care. It’s purely a tool that can be used to support process improvement that impacts patient care. Dashboards help us:
  • Set standards
  • Reduce variation
  • Define expectations

Q. How important is engagement in improving metrics?

It’s not just about getting the numbers; it’s about getting the engagement necessary to ensure everyone is rowing in the same direction. Data is, however, the knowledge that improves engagement. When leaders have access to data, they have a clearer vision of what needs improvement.
The key to our physician engagement is our Medical Leadership Council. This multidisciplinary council includes physician executives, directors of clinical services, data analysts and others to help provide a broad view of potential solutions to the issues. Site medical directors are invited to present their challenges and improvement opportunities to the council for guidance, ideas, brainstorming and best practices.
Q. How do you work with hospitals to collect and interpret data?

Our process includes interfacing with hospital clients’ systems or re-entering data from hospitals to create an overview of divisional performance. Goals are set, and our onsite team monitors for goals against our targets.

At the site level, the standard operating procedure is first to identify and prioritize metrics, and then engage with executive leadership and the Medical Leadership Council to address pain points and red flags.

Q. What are the challenges of working with hundreds of departments and hospitals, each with different approaches to measurement?

While most of us in healthcare generally are rowing forward, we’re all not rowing at the same pace or toward the same goals. Each facility may have its own area of emphasis. Ownership of the data and variation in the data are also issues. It must be re-entered, adjusted and synthesized into a standard for site-level and divisional reporting.
Most physicians and hospital have accepted that performance in the industry is based on outcomes, which are based on evidence. The industry has begun to embrace the instability of the particular measures through stabilizing the process by which performance improvement is addressed. The expectation is now that quantifiable outcomes can be applied to different targets. Data as a platform helps level this out. Within the next five years this will be considered routine.

Paul Silka, MD, FACEP, joined EmCare as an Executive Vice President with West Division in 2013 and was selected to lead the division in 2015. As the West Division Chief Executive Officer, Dr. Silka takes a data-driven approach to supporting clients in delivering service excellence and quality patient care. Prior to joining EmCare, Dr. Silka was the Chief Medical Information Officer for Cedars-Sinai Medical Center in Los Angeles. He also serves on the Board of Directors of Cedars-Sinai Health System and previously held the Chief of Staff position for the health system in 2006 and 2007. Dr. Silka was Associate Medical Director and Vice Chair of the Emergency Department from 1998 until 2008. He continues to practice emergency medicine and is Associate Clinical Professor at the Keck School of Medicine at the University of Southern California.

Jennifer McCullough, a Senior Clinical Data Analyst, joined EmCare in January 2012. She is the project manager for data management initiatives, and is responsible for developing an internal dashboard and reporting system using clinical data sourced from client hospitals. Previously, McCullough served as Project Coordinator at Methodist Health System.