Copyright © 2002‐2013 Urgent Matters 1

PARALLEL PIVOT PROCESS PHELPS COUNTY REGIONAL MEDICAL CENTER

Publication Year: 2013

Summary:

Utilizing a new pivot process in place of traditional triage.

Hospital: Phelps County Regional Medical Center

Location: Rolla, MO

Contact: Shari Riley, Director of Emergency Services sriley@pcrmc.com

Category:

A: Arrival

B: Bed Placement

C: Clinician Initial Evaluation &Throughput

Key Words:

Door-to-Doc ESI LEAN Six Sigma Patient Satisfaction Wait Times

Hospital Metrics: Annual ED Volume: 38,000 Hospital Beds: 254 Ownership: Public Trauma Level: N/A Teaching Status: No

Tools Provided:

Hahnemann University Hospital Triage Plan

Tools Provided:

Comprehensive Process Redesign PowerPoint Pilot for ED Patient Flow Pilot for Zoning for MD Cinicare Exclusion Criteria

Clinical Areas Affected:

Ancillary Departments Emergency Department Traige

Staff Involved:

Ancillary Departments ED Staff IT Staff Nurses Physicians Registration Staff Technicians

Copyright © 2002‐2013 Urgent Matters 2

Innovation Traditional triage is a linear process that proved to be dysfunctional, leading to overcrowding with negative patient satisfaction and ED inefficiency. The purpose of this triage process redesign to parallel processes was to improve operational efficiency by: streamlining patient flow; decreasing throughput time; eliminating or significantly reducing the number of patients leaving before medical screening; improving patient, provider and employee satisfaction; and overall improving delivery of care. The redesign process was developed and implemented by a comprehensive team of ED nursing staff, ED leadership, Lab, Radiology, Information Technology, ED physician contract group, pharmacy, registration, housekeeping, and decision support. Everyone's role was to provide ideas for the design of the new parallel pivot process as well as assist with implementation of the new parallel pivot process. Our facility decided to utilize lean principles to improve on throughput. Direct bedding had been tried in the past without complete success. It was discovered from past trials that a new process would need physician input as well as buy in from all involved in the ED patient care process. The redesign team utilized lean methodology to create the desired patient flow, physician zoning, ESI training, 5S methodology, and exclusion criteria for patients seen by Mid-Level Providers. ED staff received education regarding the new process changes. ED leadership presence was increased during implementation of the new process to assist with flow. A pilot was developed for parallel processes, traditional triage model changed to pivot process. Results Utilizing a new pivot process in place of traditional triage led to decreased door to provider times from average of 38 minutes to 26 minutes, decreased total length of stay from average of 191 minutes to 171 minutes, decreased left before medical screening from average of 1.72% to 1.01% and increased patient satisfaction mean score from 87.4 to 89.7. Timeline Planning began with a literature search in April 2012. A comprehensive process redesign workshop with multidepartment participation was completed on May 8, 2012. Pilot was written based on recommendations from the redesign workshop. Changes were implemented June 11, 2012. Metric were monitored weekly through the end of August. Pilot become policy and metrics continued to be monitored through the end of the year 2012. Innovation Implementation A pilot was developed and written outlining the new roles for staff during the parallel pivot process. See attached pilot for details. Patients were given a handout that outlined what to expect during their ED visit. See attached file. Physicians were zoned for increased efficiency and teamwork. See attached file. Mid-Level providers were given exclusion criteria to determine which patients should be seen by physicians. See attached file. Cost/Benefit Analysis Cost to implement this innovation was minimal. ED leadership presence was increased the first two weeks of the pilot to assist staff with implementation. No new staff or supplies were necessary. Costs incurred only consisted of productivity hours for staffing during planning and implementation. Benefit of innovation is improved throughput and decreased left without being seen leading to increased revenue from ability to see more patients. The other benefit of this innovation was to modify the nursing staffing grid to accommodate the influx of patients at the appropriate time of the day, which increases patient and staff satisfaction. No new nursing or provider positions or hours were added. Advice and Lessons Learned

1. Know the difference between a linear traditional triage process and a parallel pivot process.

Copyright © 2002‐2013 Urgent Matters 3

2. Site visit to a facility that is currently utilizing a parallel pivot process. 3. Obtain ED physician and ED staff buy in and support prior to implementing the new parallel pivot process.

Sustainability A resource to start up the innovation was a combined vision from ED leadership and physicians to improve the patient experience through the ED. Continued visionary leadership utilizing best practice to maintain the efficiency of the parallel pivot process. Tools to Download

Comprehensive Process Redesign PowerPoint

Pilot for ED Patient Flow

Pilot for Zoning for MD

Cinicare Exclusion Criteria

Comprehensive Process Redesign

Comprehensive Process Redesign (CPR) Workshop, based on Lean for Healthcare methodology, was completed for the Emergency Department on May 8, 2012.

CPR Workshop

One Full day Multidepartment participation Facilitated by Operational Performance

Consultant, Dayle Pugh Assisted by Team Health CSVP, Beth Parks Involve the people who do the work, let them

create improvement ideas makes change easier.

The Work

Walk in patient’s shoes Identify every step in overall processes Document findings Identify waste-apply lean principles

Brainstorm

Compromise Understanding Agreeing Respect Committing Envision “An Ideal Process” Design a new “ideal” process

Ideal Process

Value as perceived by the patient Eliminate non-value-added steps Design the system that delivers value from

beginning to end based on the expressed needs of the patient.

CPR/LEAN June 2012 Goals

Begin with an understanding of the customer – Come to ED See a Doctor

CPR/LEAN Goals June 2012

Reduction of waste; time and resources (supplies and staff), used to provide a service that exceeds expectations.

Eliminating waste creates a more efficient process Efficient use of FTE’s Immediate available beds Increases census and revenue Lean thinking is using less to do more

CPR/Lean June 2012 Goal

The goal of the workshop was to design a process to improve operational efficiency of the Emergency Department.

Outcomes

Expected outcomes of improved operational efficiency are: streamlined patient flow; decreased throughput time; eliminate or significantly reduce the number of patients leaving prior to treatment (LWOT); improved patient, provider and employee satisfaction; and overall improved delivery of care.

Summary of Emergency Department Comprehensive Process Redesign

Issue: Pts arriving to the ED fill out form handed to them by a clerk and wait to be seen by RN. Linear processes causing delay of patient evaluation by a triage nurse. Patients frequently are sent back to the waiting room because no beds are open by mid-day. Back log occurs and late evening, night shifts are overloaded with patients who arrived much earlier in the day.

Background:

38,325 annual volume D2D 48 min average LOS 182 min for discharge pt LOS 303 for admitted pt LWOT 2.4% Patient Sat at 78th percentile 0.6% ESI level 1 22.8% ESI level 2 48.4 % ESI level 3 27.8% ESI level 4 0.5% ESI level

Future State / Target Condition:

Direct flow of patient to provider for all ESI levels. Pivot nurse greets patients, triage with ESI determination within 5 minutes of arrival. Direct bed placement in Main ED, RMA /Intake or D side. Reassignment of current providers and nursing staff to accommodate new flow. Empty lobby and rapid flow of upright patients.

Countermeasures:

Change traditional triage model to Pivot nurse function with patients being seen first by RN. Triage reduced to a “sick-not sick” sorting function with patients going directly to open treatment space.

Treatment space options will include: Main ED for ESI 1’s, 2’s, “high” 3’s. Side D for “low 3’s, 4’s and 5’s needing procedures. RMA (Rapid Medical Assessment) for 4’s and 5’s not needing procedures AND for use as Intake when all beds in department are full.

Goals:

D2D 30 min or less LOS 167 or less for all pts LWOT less than 1% Increase in patient satisfaction Elimination of queuing Empty Lobby RN at front with ESI in 5 minutes Direct Bedding

New Process Changes

Admission assessments/vital signs done by primary nurse in back (unless patient being sent to lobby when no space is available, then pivot nurse will obtain additional assessment and vital signs).

New Process Changes

Enhance Side D to model that creates virtual bed space to prevent patients being sent to lobby after triage. Side D open 10a-10P, staffed with MLP, RN and Tech 7 days per week. Will see ESI low-3’s, and 4’s and 5’s that require procedures

New Process Changes

Patients seen in parallel process by MLP and RN for assessment, then moved to inner waiting space (either Holding area or Flu waiting room) for labs, x-ray. Then moved to private room on Side D when ready for discharge. Bed rotation and Upright patient flow.

Creation of RMA/Intake area during high volume times 7 days a week.

Intake to be in current triage rooms. Low 4’s and 5’s can be seen and released, or sent to inner waiting in Holding room to await test results/x-rays. This area to be open noon-midnight Sat-Sun-Mon-Tues and 2p-7p Wed-Thurs-Friday. Staffed with MLP, RN and Tech. Utilize parallel processing and upright patient flow.

Rapid Medical Assessment Intake

Note that during times when no beds are available in the Main ED or side D, this RMA/Intake area can see all comers with pt care initiated and pts transferred out to Main ED beds to keep flow moving and prevent ESI 3’s from spending lengthy times in WR.

Admission Current State

Clerk at front to greet patients, patients have to fill out form and then sit in WR to await triage. Triage nurse called from back via radio – triage nurse waits for paperwork to be completed and transports patient back to assigned room (if available) and may or may not complete triage assessment at the bedside prior to coming back to front of ED.

Admission process continued

Patients wait for triage nurse to return. ESI 3, 4 and 5 patients frequently sent to lobby starting in early afternoon.

Increased risk Decreased patient satisfaction

Countermeasures and Implementation

Pivot nurse/quick look triage model goal with RN staying up front during busiest hours of patient arrivals (9a-11p) Patient greeted by RN first with ESI assigned within 5 minutes of arrival.

Implementation

Tech staffing shifted to assist Pivot nurse in transporting patients to rooms during high volume times.

Initial registration to include name, date of birth, social security and sign consent to treat.

Implementation

Full registration and consent completed after MSE. Quick Registration done in parallel process with pivot triage.

Problem Analyses:

Pts wait over 45 minutes to see a provider due to linear processes and delays getting patients to a room to be seen.

Problem Analyses

Variable practices and delays by providers and extended LOS with upright patients unnecessarily remaining in a bed while waiting procedures/results/ discharge.

Physcian Zoning

Physician: will be zoned to improve communication, patient care, patient flow, patient safety, and efficiency of time and effort of staff’s work.

Physician Zoning

Shift Manager: will make assignments and ensure that all staff’s work loads are reasonable. Will communicate with all staff continually to ensure that zoning and patient-centered care is being provided rendering the best possible patient outcome for every patient and staff member

Process of the ED Zoning

There will be 2 different flows: Sat, Sun, Mon, Tues will be one zoning

flow (Weekend Flow) Wed, Thurs, and Friday will be a different

zoning flow (Mid-Week Flow) Due to staffing of MLP’s and nurses as

well as patient census

Weekend Flow

6a doctor: zone will be “A” side (and 17-20 until 0900)

9a doctor: zone will be “B” side 10a MLP: zone will be “D” side

(as intake until 12n; then worked as rapid treatment area and soft “3s”)

12n MLP: zone will be “Intake” 2p doctor: zone will be “C + 1 & 20”

(until 7p then B + 12&13) 6p doctor: zone will be “A + 9 & 10”

Mid-Week Flow

6a doctor: zone will be “A” side (and 17-20 until 0900)

9a doctor: zone will be “B” side (until 1400 then to “C & D side until 1900)

10a MLP: zone will be “D” side (until 1400 then to intake till 1900 then back to D side)

2p doctor: zone will be “B” side (at 1900 add rooms 12 & 13)

6p doctor: zone will be “A” side (at 1900 add rooms 9 & 10)

Test and Follow Up

Follow process closely after go-live (LWOT, LOS for all pts and Door to Doc times). A PDCA process is recommended with suggestions for adjustments in flow to be brought to ED Action Team prior to change. No “free lancing” by individuals.

“5 S” efficiency opportunities were discovered-Team developed

Process of obtaining supplies for IV starts -Utilization of injectable lidocaine vs. spray for IV

starts -Placement of dressing/splinting supplies for Side D -Packaging of “take home” medications by pharmacy -Stocking of bedside cupboards/drawers -Stocking of instrument cart

5 S Team

The team will continue pursuing “5S” efficiency projects started during this workshop. Note the presence of pharmacy, radiology, ultrasound representatives during the workshop was invaluable to this process

Parking Lot Issues

Several items were brought forward for discussion during the workshop – further investigation and planning are necessary to provide solutions to these issues.

– Point of care testing – Tracker board utilization in ancillary departments – Bedside charting-utilization of modern IT capabilities – Communication devices – Room numbers on orders for phlebotomist

Secondary Gains

Team Building Camaraderie Team Satisfaction & Ownership of Process Staff Building Efficiency and Reliability of Care Patient Safety Patient Satisfaction

Phelps County Regional Medical Center ED Patient Flow

The Emergency Department will begin a pilot of “ED Zoning” to begin 6/11/12 this pilot will run through 6/29/12 when it will be evaluated for success. This process/pilot will work hand-in-hand with the zoning pilot. The purpose of this pilot is to:

• Improve patient safety and satisfaction • Improve Door to Provider time (Rapid Medical Exam/Intake) • Decrease patient LOS, LBMS and Elopements • Increase communication throughout all disciplines in the ED • Increase efficiency and decrease unnecessary steps • Keep patients upright and rapidly moving through department • All ED care is Patient-Centered

Process of the ED Patient Flow:.

• Pivot Nurse: this will be a 4 hour rotating position with the intake nurse and D-side nurse. The pivot nurse will be stationed in front of the registration area with a Computer-On-Wheels, portable pulse oximeter, radio, and registration forms. The first person to greet the patient will be the pivot nurse --- rapid assessment of “Sick or Not Sick” will be done upon patient’s arrival to the ED. Visual assessment…does the patient look sick or not sick? If sick the patient goes directly to the main ED to be registered and triaged in the ED room by the primary RN (remember zoning and placement of patients must be equally distributed). If not sick ask these questions to the patient: what brings you to the ED today? When did this start? What is your pain level? If needed pulse ox and heart rate. On the registration form write the chief complaint and ESI level and any of the above data obtained. Send the patient with the registration form to registration for quick registration and arm banding then direct them to go to the large patient waiting room after receiving their arm band. The pivot nurse will instruct the roving tech to take patients to all the appropriate areas. ALL paper work stays together (registration and patient’s chart). The keys are to keep patients upright, no patient owns a bed, rapid treatment, and rapid disposition. You will be responsible to restock, clean, and straighten the work area after your shift.

• Intake tech: This is a key role to success. Constant communication with pivot nurse, intake nurse, and D-side staff to ensure patient process flow is appropriate. You will be responsible for taking all “Sick Patients” to the main ED and to ensure you are met in the room by main ED staff…once staff is in the room with the patient you must return to the front area. You are responsible for taking patients to radiology and obtaining UAs from the Area 51 patients. You will be responsible for assisting the pivot nurse and intake staff with patient flow. You will be responsible to ensure that patient’s charts follow the patient to the

appropriate areas. You will be responsible to restock, clean, and straighten the work area after your shift.

• Intake RN/MLP: starting at 1000 every day this will occur on D-side in room #23. Once the “Not sick” patient has been registered they will go to room #23 for a rapid assessment by the MLP and RN (10-15 minutes at the most). All assessments and care of the patient will be performed in a parallel process with the MLP and RN to ensure efficiency and rapid care. If a horizontal procedure needs to be done the patient will be placed in a room on D-side…if the patient only requires tests or waiting for discharge, they are placed in “Area 51.” At noon (Sat, Sun, Mon, & Tues) intake moves to the triage room and on Wed, Thurs, & Fri intake will be in the triage room from 1400-1900. Intake staff must be in constant and close communication with the pivot nurse and D-side staff to ensure that all patients are processed and cared for efficiently. The keys are to keep patients upright, no patient owns a bed, rapid treatment, and rapid disposition. You will be responsible to restock, clean, and straighten the work area after your shift.

• D-side staff: this RN and tech will be in close and constant communication with the pivot nurse and intake nurse to ensure that all patients in “Area 51” as well as D-side are processed and cared for quickly and efficiently. Patients on D-side as well as throughout the department DO NOT OWN THE BED. Once their procedure or treatment has been completed they are to be moved to “Area 51” to wait disposition. You will be responsible to restock, clean, and straighten the work area after your shift.

• Area 51: All patients in this area have been seen by a provider and can be fully registered…their charts will be on the wall in the new chart rack. This area has been designed to allow patients and their family to comfortably wait for lab, x-ray, disposition, medication, or splinting. The room across from the bathroom provides privacy for lab draws, shots, and/or discharge instructions. These patients are the responsibility of the pivot, intake, and D-side staff. The main ED can utilize this area for patients to wait for disposition when main ED beds are needed. However, it will be the responsibility of the PRIMARY RN to discharge the patient (continuity of care and patient satisfaction/safety issue).

• Registration staff: In the front the pivot nurse will have the form and will write on it with the chief complaint as well as other information as listed above, the patient will bring the form to registration at which time they will be asked their name, DOB, and last 4 digits of their social, then they will sign a consent to treat then an arm band will be placed on the patient. This form will be attached with the chart. Registration staff will need to be mobile and roving throughout D-side and Area 51 beginning 1000. All patients located in Area 51 can be fully registered…the registration form will be on their charts located on the wall in the new chart rack. Staff must be diligent to complete registration ASAP as this new process flow will decrease LOS for patients in the department.

• Shift Manager: Must be in constant communication with pivot nurse, intake, D-side, registration, and providers. Shift managers MUST ensure that process flow is followed and all care is patient-centered. Shift managers must ensure zoning and work load is equal. Must ensure that all patients are registered prior to

discharge. Must round and ensure that “Key Phrases” are used throughout the department. The keys are to keep patients upright, no patient owns a bed, rapid treatment, and rapid disposition.

• MLP/Physicians: Intake is a rapid parallel assessment done with the intake nurse on “Not sick” patients. This process should take 10-15 minutes. Once the assessment has been completed the patients will be directed to the appropriate area for treatment and or disposition. Dispositions will be done in Area 51 for “not sick” patients with privacy provided. Patients requiring procedures on D-side will receive their procedure and then will be taken to Area 51 to wait for disposition. The keys are to keep patients upright, no patient owns a bed, rapid treatment, and rapid disposition.

Monitoring & Measuring Pilot project: • Monitor appropriate patient placement and ESI level • Monitor LOS, MSE, LBMS, and Elopements • Monitor Staff satisfaction • Monitor registration process • Monitor Core measurement compliance • Monitor Work Load • Monitor compliance of all team members

i. Observation ii. Documentation

iii. Satisfaction • Monitor patient safety, satisfaction, metrics • Track/Trend

In-servicing Staff: Prior to the project a member of the team will meet with you to discuss the pilot project and your involvement in helping us achieve our goals. This will be done through the BOSH. At that time I am asking for you to give any suggestions, concerns or perceived roadblocks so we can adequately address them. Additionally, you will be asked to help collect data during and following the pilot project. This will assist us in knowing if the change is an improvement. Thank you for your active participation and for y our willingness to help us improve the services we provide to our community. Together we make the PCRMC difference! 6/1/12 gs

Phelps County Regional Medical Center ED Zoning for MD

The Emergency Department will begin a pilot of “ED Zoning” to begin 6/11/12 this pilot will run through 6/29/12 when it will be evaluated for success. The purpose of this pilot is to:

• Improve patient safety and satisfaction • Decrease patient LOS in the ED • Increase communication throughout all disciplines in the ED • Increase efficiency and decrease unnecessary steps • All ED care is Patient-Centered • Ensure core measures are met on all patients

Process of the ED Zoning:. Department Flow

• 6a doctor: Zone will be A-Side Rooms 1-10; then at 2p zone becomes rooms 2-8.

• 9a doctor: Zone will be B-Side Rooms 11-20; then at 2p zone becomes rooms 11-19.

• 10a MLP: Sector will be D-Side Rooms 21-25 and Area 51 • 2:30 pm MLP: Sector will be D-Side and Area 51. Intake Area will

be open as deemed necessary by shift manager. • 2p doctor: Zone will be C-Side with Rooms 1 & 20; at 7p zone

becomes 11-20 • 6p doctor: Zone will be rooms 1-10

Roles in the project: (participants)

Physician: will be zoned to improve communication, patient care, patient flow, patient safety, and efficiency of time and effort of staff’s work.

Shift Manager: will make assignments and ensure that all staff’s work loads are reasonable. The Shift Manager will communicate with all staff continually to ensure that zoning and patient-centered care is being provided rendering the best possible patient outcome for every patient and staff member. The Shift manager will rotate staff as needed to ensure that all zones are running efficiently. The Shift Manager will communicate with pivot nurse to ensure that patients are placed in appropriate sectors for all shifts and will ensure that all care is patient-centered. The Team: Will ensure that all care given is patient-centered. The team will work as a team in the assigned zones. The team will work proactively to provide safe and efficient care for all patients. The Team will give feedback to shift manager regarding work load, patient flow, process improvements, and patient satisfaction. The Team will be efficient and will be responsible for triaging,

treating, moving, and discharging all patients in their zone. The Team will be responsible for effective communication skills.

Monitoring & Measuring Pilot project: • Monitor appropriate patient placement • Monitor LOS and MSE • Monitor Staff satisfaction • Monitor Core measurement compliance • Monitor Work Load • Monitor compliance of all team members

i. Observation ii. Documentation

iii. Satisfaction • Monitor patient safety, satisfaction, metrics • Track/Trend

In-servicing Staff: Prior to the project a member of the team will meet with you to discuss the pilot project and your involvement in helping us achieve our goals. This will be done through the BOSH. At that time I am asking for you to give any suggestions, concerns or perceived roadblocks so we can adequately address them. Additionally, you will be asked to help collect data during and following the pilot project. This will assist us in knowing if the change is an improvement. Thank you for your active participation and for y our willingness to help us improve the services we provide to our community. Together we make the PCRMC difference!

EXCLUSION CRITERIA for Mid-Level Care in the Emergency Department Abdominal pain Back pain (traumatic/injury < 48 hrs) Chemical Burns Chest Pain Child <6 months of age Conscious sedation Diabetes-related issue Diarrhea Electrical injury Epistaxis Eye injury (penetrating trauma) Fever >103 degrees (any age) Fracture (open) Frostbite Head Injury with LOC or neuro deficits Headache MVA <48 hours Neck injury Needs Oxygen Penetrating injury Petechial rash Pulse ox <95% Pulses absent Seizure Sexual Assault SOA Spine injury Syncope Ulcers (gastric) Vision loss Vomiting