A cross-functional effort to identify and eliminate bottlenecks is leading to vastly improved length of stay (LOS) results for Emergency Department (ED) discharged patients. The goal was to improve the ED’s overall patient experience by reducing the length of time required to diagnose and treat patients who are discharged.
The initiative was led by Sudhan Gowrish Chinnappan, process engineer with Houston Methodist’s System Quality & Patient Safety Department, who partnered with the ED’s leadership, shared governance team, physicians, and advanced practice providers. The project was conducted over several months and went into effect in early June.
The payoff was immediate, with an improvement on average ED LOS for all discharged patients, achieved primarily by decreasing the time that patients wait to see a provider by 30 minutes. The total time patients spent in the ED, from check-in to discharge, decreased by 40 minutes. The team utilized a lean manufacturing approach called a “kaizen” event – essentially a three-day brainstorming session – to identify the barriers to improving LOS and discuss possible solutions. The actions are then tested at the unit level to mature into solutions (kaizen is a Japanese word that simply means “small change”).
“The key to kaizen is involving front-line staff and allowing them to come together without interruption, to really focus on the issue,” said Chinnappan. “After all, who knows better than the people on the front lines? The kaizen event gives us an opportunity to really dig into what matters and what we are trying to achieve, identify the root causes behind bottlenecks that slow us down or create wasted effort, and plan countermeasures with representatives from all the critical functions participating.”
As preparation, Chinnappan spent about six weeks interviewing personnel, observing patient flow and through data analysis, measuring the length of time it took individual patients to move from step-to-step in the ED.
The team’s first task was to develop a detailed process map that outlined each stage in the patient’s journey. Next team members identified the root causes for delays that had the most impact on discharge times and set about developing countermeasures that could be implemented for evaluation.
One of the key issues identified was intermittent surges in patient volume, which overloaded staff and created delays in the check in process. To counter this, the team identified a number of mechanisms that can be implemented to mobilize additional resources well before the ED fills up. For example, one successful approach is creating intentional teamwork by identifying and assigning team members with stable assignments to assist with triaging (sorting by acuity) before the system is overwhelmed. In some cases, ED physicians have even come to the front to triage patients and help speed the transition. The same intentional approach is led by the charge nurse when there are a surge of patients waiting to be discharged.
“We are continuing to tweak the measures we implemented, but so far the response has been great,” said Chinnappan. “We’ve had active participation from everyone, including senior management and our physicians. The pride in their work has helped sustain the improvements and seek new areas to get better.”
“In addition to providing structure and clear-cut processes, kaizen also empowers people to act because they better understand the overall departmental objectives and how they can help,” said Chris Siebenaler, regional senior vice president and CEO of Houston Methodist Sugar Land. “Sometimes it’s the little things that make a difference in terms of heading off a bottleneck or responding to increased volume. When people see others stepping up, eventually you change the culture and the results change, too. It’s fantastic to see what our ED team has achieved.”
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