We’ve implemented lean processes to improve ED throughput and decrease ambulance diversion hours. Looking to make further improvements in throughput, particularly in reducing time-to-provider, we moved triage to the waiting room in an effort to remove bottlenecks and conduct more timely patient assessments.
A Happy Ending?
From an ED metrics perspective, waiting room triage was a smashing success, with time-to-provider dropping from 32 minutes to 19 in the span of six months.
A success story with a happy ending, right? Not quite.
Unfortunately, many of our patients told us that they didn’t like being assessed in the waiting room. Despite setting up workstations to facilitate privacy during the triage process, many patients felt that the area just wasn’t private enough.
Our group always tries to put patients at the center of everything we do, and that means listening to what patients want and need. So, after almost two years, we discontinued waiting room triage and moved the process back into the main ED.
To help preserve our time-to-provider and throughput gains, we used the extra staffing we now had in our Rapid Medical Evaluation (RME) area to open more ED rooms earlier in the day. We also instituted direct bedding for unstable cases and likely admissions. This kept most of our patients moving efficiently through the department.
However, we were still having trouble with moderate-acuity patients — specifically our level 3s, who needed more complex care than we could provide through RME. To address this issue, we instated a modified thriage process.
Thriage allows us to quickly assess, treat, and disposition level 3s, who often face the longest ED wait times. Patients are kept vertical when possible to free up rooms for those who truly need them. This has helped to decrease turnaround times for these patients while making efficient use of our resources.
Recognizing Failures as Success
I share these challenges with you today to illustrate the point that not all hospital improvement initiatives are going to be successful. It’s just not realistic.
No one likes to talk about unsuccessful initiatives, but they’re quite common. In fact, 70 percent of hospital CEOs reported failed strategic initiatives at their organization.
As healthcare providers, we are trained and strive to minimize risk, to ensure that we’re delivering the safest care we can. While we don’t take risks when it comes to patient safety, taking risk in advancing healthcare is vital. It is an important part of innovating new ideas and approaches.
As healthcare continues to evolve at a faster and faster pace, only those organizations that have innovation as a key component of their strategy will succeed and survive. But achieving success in innovation and transformation requires taking risks and recognizing failures as success. Because when people aren’t afraid to fail, they feel empowered to take risks and accomplish amazing things.
Practice Management Support
So, back to our process improvement initiatives.
Our hospital previously had a very active and engaged interdisciplinary “lean team” led by two highly trained lean specialists. This group had been instrumental in helping us analyze our ED processes and develop waiting room triage. Unfortunately, shortly after our waiting room triage setback, we faced a second setback: the hospital’s lean team dissolved. We no longer had the support of lean specialists.
Our interdisciplinary team continued to meet, gathering representatives from the ED, nursing, radiology, laboratory, registration and other departments. But while I have some lean training, I am far from an expert in lean methodologies and, therefore, not equipped to lead a big process improvement initiative.
Fortunately, we have ongoing support from Vituity’s practice management consultants (PMCs). With clinical and business backgrounds, the PMCs partner with us to conduct operational assessments and implement process improvement best practices. Because many of the changes to our triage processes involve our physician assistants and nurse practitioners, the PMCs also provide significant support and mentoring for these providers.
Our PMCs also provide valuable data on things like volume per hour and turnaround times based on ESI levels. That information helps us determine our strengths and weaknesses and how to staff our department optimally. Personally, I believe the PMCs at Vituity set the organization apart from other physician management and staffing companies in the country. The level of collaboration and support they provide is unparalleled.
The Promise of Innovation
Our interdisciplinary improvement committee will continue its focus on increasing throughput in our busy ED, building on the lean work already completed. As we work to improve efficiencies in the ED, as well as lab and radiology, we’ll keep refining and improving our triage process.
While throughput has slowed down a bit since we discontinued waiting room triage, our ED was still recognized recently for having some of the shortest wait times in Portland. Not bad for a high volume, urban ED.
While we're still working to refine our new front-end processes, I've been impressed by our team's ingenuity and flexibility. I'm confident that with the help of our committee and consultants, we'll get there.
With the fast pace of change in healthcare, the future is uncertain, but we’ll keep adapting to continually improve our ED. Will we make some mistakes along the way? Probably. But only through thoughtful risk-taking (and failures) as we innovate will we be able to deliver the best care we can.