Gold - Patient Flow Initiative DGH ED Part 1

DGH Emergency Department
Wait Time Improvement Project:
Part 1 Patient Fast Track
Quality Week May 29, 2014
Acknowledgements - Project Team
Name
Title
Project Role
Lori Sanderson
Health Service Manager
Co-Lead
Liam Shannon
Management Engineer
Co-Lead
Ravi Parkash
Chief, Emergency Medicine
Co-Lead
Mark McMullen
MD
Contributor
Albert Williams
MD
Contributor
Don MacQuarrie
MD
Contributor
Heather Peddle-Bolivar
MD
Contributor
Sherry Lynne Jessome
RN / Clinical Nurse Educator
Contributor
Pam McKinnon
RN
Contributor
Carolyn Peters
RN
Contributor
Nancy Strickland
RN
Contributor
Channa Lee Haas
RN
Contributor
Lee Mailman
RN
Contributor
Arlene White
RN
Contributor
Trisha Sanford
RN
Contributor
Jean Law
RN
Contributor
Cynthia Hodgins
RN
Contributor
Heather Francis
Health Services Director
Sponsor
p
/ Support
pp
Barbara Hall
VP Person-Centered Health
Sponsor / Support
Dave Urquhart
IT ED
Contributor
Sherri Lamont
Admin Assistant, DGH ED
Contributor, Admin Support
Overview
• Background
o
o
o
o
The Problem
Th
P bl
The Challenge
Strategic Alignment
E i
Equipped
d ffor Ch
Change
• Project Execution
o
o
o
o
o
o
o
Methods
Patient Satisfaction Drivers
Core Focus
Baseline Measures
Proposed Solution
Required Operational Changes
Success Factors
• Statistical Results
Background
2011 / 2012:
Hospital Capacity
• DGH Hospital Occupancy > 100%
• ED Volume approaching 40,000 visits per year
• LOS Admitted Patients in the ED 22 – 25 hours
Emergency Department
•
•
•
•
Increasing Wait Times
Increased left without being seen (LWBS)
Patient complaints and poor patient satisfaction
Frustrated and stressed Staff
Background
45
40
35
LOS
S (hours)
30
25
20
15
10
5
0
90th %ile
Defining the Problem
Problem focus areas
o Patient wait times excessively long
o Not meeting desired customer service level
o Not satisfying patient expectations
o Not
N t effectively
ff ti l managing
i patient
ti t demand
d
d and
d flflow
in the ED
The Challenge
Department
p
was challenged
g by
y
Administration to maximize efficiency and
improve patient satisfaction without the
addition of major resources
o Find ways to do better with the same
o Ensure the ED is a sustainable system
Strategic Alignment
Aligned with Capital Health’s renewed
organizational strategy - Our Promise in Action:
o Build
B ild a culture
lt
off customer
t
service
i
Transforming the Person-centered Health Care Experience
o Strengthen accountability of employees and Physicians
Transformational Leadership
o Innovate systems and processes for greater efficiency
Sustainability
Equipped for Change
• Fall 2013: Stable staffing situation, major free agent
signing
i i
• Keen,
Keen new
new, young staff willing to embrace change
• Manyy staff came from other departments
p
across the
country bringing different ideas and experience
• Concentrating on flow issues within the control of the
ED
• Clear focus and objectives
Methods
The initial project work consisted of a
comprehensive assessment of the system
• This work included:
o
o
o
o
o
o
An environmental scan
Process Mapping
Data collection
Review of ED resource capacity
Team discussions
Analysis
Drivers for Patient Satisfaction
• Major drivers for patient satisfaction in ED visits
–
–
–
–
–
Empathy / Attitude
Timeliness of Care (waiting time)
Technical Competence of Care Providers
Pain Management
Information Dispensation
• Minor drivers for patient satisfaction in ED visits
–
–
–
–
Cleanliness
Comfort in waiting room
Privacy
Noise levels
“Leading Practices in Emergency Department Patient Experience”,
Ontario Hospital Association (2010/2011)
Core Focus
• During the literature review, a highly compelling quote
stood out and became the core focus for the team
“Ensuring
g the most rapid
p p
possible contact with a p
physician
y
satisfies the
desires of ED patients, promotes efficiency of care and shortens length
of stay”.
Leading practices in Emergency Department Patient Experience; Ontario
Hospital Association (2010/2011)
Goal: Decreased door to doctor time for CTAS 4 and 5 patients
Satisfaction Survey
Baseline Measures
Critical to Quality
Performance Metric
CTAS 4
CTAS 5
Weeklyy mean door to doctor
time
132.1 minutes
126.7 minutes
Weekly mean length of stay
233.6 minutes
197.5 minutes
Weekly 90tth percentile
240 2 minutes
240.2
217 5 minutes
217.5
Weekly % <90 minutes
36.5%
39.7%
Team Findings
Low acuity
yp
patients have long
g wait times
impacted by...
•
Traditional model of Triage-Registration-Waiting Room- ED bed
•
Traditional nurse then physician model
•
Traditional use of physical beds
•
Staffing hours not aligned with demand
Proposed Solution
• Creating a fast track into the ED for low
acuity patients by...
• Challenging the three existing paradigms
o Revising the traditional flow of patients into the
department
o Changing the way we used physical beds
o Minimizing
g the nurse first model
Required Operational Changes to
Support The New Model
• Role of registration clerk was expanded to direct low acuity
patients directly into the ED
• The flow of the patient’s
patient s chart changed
• The concept of patients being screened by the nurse was
introduced
• Changes to physical space were made
• The hours of operation of the fast track area were adjusted
• RN/MD staff hours were adjusted
Success Factors
• Started with a blank slate
• Focused on the pieces of the process within ED control
• Worked with a specific and definable objective
• Attempted to control distraction
• Continual monitoring and check ins
• Supported team work and collaboration
Statistical Results
“Ensuring the most rapid possible contact with a physician satisfies the
desires of ED patients
patients, promotes efficiency of care and shortens length
of stay”.
Leading practices in Emergency Department Patient Experience; Ontario
Hospital Association (2010/2011)
Our core focus helped to define our testing hypotheses:
•
•
•
Will the planned changes have an impact on rapid contact with
Physicians?
Does rapid
p contact with a Physician
y
satisfy
y the desires of the
patient?
Does rapid contact with a Physician promote efficiency of care
and shorten length
g of stay?
y
Critical to Quality Measures
1. Weekly % of CTAS 4 and CTAS 5 patient going directly to waiting
room
This metric is to ensure that the opportunity for quicker access to physician is
possible by placing patients in an area where the next phase of treatment may
occur
2 Weekly mean Door to Doctor for CTAS 4 and CTAS 5 patients
2.
Based on the core focus of satisfying the desire of rapid access to Physician
assessment
3. Weeklyy 90th p
percentile door to doctor time for CTAS 4 and CTAS 5
patients
Ensure that the metrics are not only responding to central data tendencies but
also the variation in performance
4 Weekly % of patients with Door to Doctor time <90 minutes for CTAS 4
4.
and CTAS 5 patients
Aligning performance with a defined standard of care for low acuity ED patients
5. Weeklyy mean length
g of stay
y for CTAS 4 and CTAS 5 p
patients
Based on the presumed correlation between rapid contact with Physician and
shortened length of stay
Flow Logic
Mayy still take some time to see a Doctor,
However:
• P
Patients
ti t in
i Physician
Ph i i assessmentt queue supports
t
patient flow – Patients are accessible and ready to be
seen, visual queue of pending workload
• Patients in a location where the next phase of
treatment may take place
• In the correct queue; waiting room adds no value to
patient
ti t experience
i
Intake and Patient Flow
Low Acuity Direct to Waiting Room
Percentage of low acuity Patients Direct to Waiting
Room
98.0%
96.0%
94.0%
92.0%
90.0%
88.0%
86.0%
Low Acuity Direct to Waiting Room
Percentage of Patient Direct to Waiting Room
120.0%
100.0%
80.0%
60.0%
40.0%
20 0%
20.0%
y = -0.0018x + 73.461
0.0%
Weekly Mean Door to Doctor
CTAS 4 Weekly Mean Door to Doctor Time
250 0
250.0
200.0
150.0
100.0
50.0
0.0
y = -0.0481x
0 0481 + 2105
2105.5
5
Weekly Mean Door to Doctor
Pre and Post January Weekly Mean Door to Doctor Team
200
150
100
y = -0.2203x + 139.39
50
y = -0.3077x + 118.2
0
1
3
5
7
9
11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67
Pre January
Post January
03-Mar-14
4
03-Feb-14
4
03-Jan-14
4
03-Dec-13
3
03-Nov-13
3
03-Oct-13
3
03-Sep-13
3
03-Aug-13
3
03-Jul-13
3
03-Jun-13
3
03-May-13
3
03-Apr-13
3
03-Mar-13
3
03-Feb-13
3
03-Jan-13
3
03-Dec-12
2
03-Nov-12
2
03-Oct-12
2
03-Sep-12
2
03-Aug-12
2
03-Jul-12
2
03-Jun-12
2
03-May-12
2
03-Apr-12
2
03-Mar-12
2
03-Feb-12
2
03-Jan-12
2
03-Dec-11
1
03-Nov-11
1
03-Oct-11
1
Axis
s Title
90th Percentile Door to Doctor
90th Percentile
350
300
250
200
150
100
y = -0.0487x + 2239.6
50
0
CTAS 4 Door to Doctor < 90 mins.
Door to Doctor Time < 90 Minutes
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
y = 0.0003x - 10.524
CTAS 4 LOS
CTAS 4 Weekly Mean LOS
350
300
250
200
150
y = -0.0512x + 2335.2
100
50
0
CTQ Statistical Results
Low acuity weekly statistics
((door to doc and LOS))
Pre
January
y
th
14 2013
Post
January
y
th
14 2013
CTAS 4 (mean)
132.1
110.8
21.3
Yes
CTAS 5 ((mean))
126.7
108.3
18.4
Yes
CTAS 4 (median)
118.8
94.5
24.3
Yes
CTAS 5 (median)
113.1
93.1
20
Yes
CTAS 4 90th percentile
240 2
240.2
217 5
217.5
22 7
22.7
Yes
CTAS 4 90th percentile
228.5
200.6
27.9
Yes
CTAS 4 % of patients < 90 min
36.5%
48.4%
11.9%
Yes
CTAS 5 % of patients < 90 min
39.7%
49.6%
9.9%
Yes
CTAS 4 LOS
233.6
210.9
22.7
Yes
CTAS 5 LOS
197.5
180.6
16.9
No
Delta
Means
statistically
y
different?
Two sample t-test at 95% confidence interval used to test results
Post Implementation Survey
Results
Survey Statistical Results
Survey Question
Pre
mean
score
Post
mean
score
Delta
Means
statistically
different?
I was seen in triage (first assessment) in a reasonable amount
of time
4.05
4.48
0.43
Yes
I was seen by a doctor in a reasonable amount of time
2 37
2.37
3 38
3.38
1 01
1.01
Y
Yes
I received care, and treatment in a reasonable amount of time
2.18
3.84
1.66
Yes
Throughout my visit, I (or family / friends / care giver) was kept
informed about tests and treatments
2.42
3.32
0.9
Yes
I (or family / friends / care giver) was kept informed about tests
and treatments
3.11
3.73
0.62
Yes
I (or family / friends / care giver) felt understood and cared
about
b tb
by th
the emergency staff
t ff
3.39
4.1
0.71
Yes
3.5
3.79
0.29
No
2.88
3.69
0.81
Yes
Throughout my Emergency Department visit (triage,
registration, tests, and treatment), my pain level was managed
in a timely manner
Staff kept me (or family / friends / care giver) informed about
the next steps in care
Two sample t-test at 95% confidence interval used to test results
What is the data telling us?
“Ensuring the most rapid possible contact with a physician satisfies the
desires of ED patients
patients, promotes efficiency of care and shortens length
of stay”
Leading practices in Emergency Department Patient Experience; Ontario
Hospital Association (2010/2011)
•
•
•
Have we impacted rapid contact with Physicians?
Does rapid
p contact with a Physician
y
satisfy
y the desires of the
patient?
Does rapid contact with a Physician promote efficiency of care
and shorten length
g of stay?
y
Continuous Improvement
• Team celebrated success of the work, but
recognizes
i
th
thatt this
thi iis a work
k iin progress
• Even with the 12% improvement in low acuity
patients seen by a doctor within 90 minutes, there is
still work to be done
• The team still meets regularly to monitor the
performance metric statistics
• The team is moving into a 2nd phase with a focus on
high acuity patients
Some Encouraging Words
•
“Even when it is busy, there is a sense that we can manage.”
–
•
"The changes in the department have made a huge difference, for patients and
morale.“
–
•
ED Ph
Physician
i i
“I am from Truro and have been to emergency rooms many times. This one is
undoubtedly the fastest, friendliest and best one ever! Thanks for all the help
and care!”
–
•
ED RN
“Now there are always patients ready for me to see, instead of waiting for
patients to be brought in from the waiting room.“
–
•
ED RN
Patient Survey Comment
“This
This was the fastest time to see a doctor, the doctor was very professional.
Rate him a 10 out of 10.”
–
Patient Survey Comment

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