DGH Emergency Department Wait Time Improvement Project: Part 1 Patient Fast TrackQuality Week May 29, 2014
Acknowledgements - Project Team
Name Title Project RoleLori 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 ContributorDon 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 ContributorArlene White RN Contributor
Trisha Sanford RN Contributor
Jean Law RN Contributor
Cynthia Hodgins RN Contributor
Heather Francis Health Services Director Sponsor / Supportp pp
Barbara Hall VP Person-Centered Health Sponsor / Support
Dave Urquhart IT ED Contributor
Sherri Lamont Admin Assistant, DGH ED Contributor, Admin Support
Overview
• BackgroundTh P blo The Problem
o The Challengeo Strategic Alignment
E i d f Cho Equipped for Change
• Project Executiono Methodso Patient Satisfaction Driverso Core Focuso Baseline Measureso Proposed Solutiono Required Operational Changeso 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 TimesIncreasing Wait Times• Increased left without being seen (LWBS)• Patient complaints and poor patient satisfaction • Frustrated and stressed Staff
Background
35
40
45
25
30
S (h
ours
)
10
15
20
LOS
0
5
90th %ile
Defining the Problem
Problem focus areaso Patient wait times excessively long
o Not meeting desired customer service level
o Not satisfying patient expectations
N t ff ti l i ti t d d d flo Not effectively managing patient demand and flow
in the ED
The Challenge
Department was challenged byp g yAdministration to maximize efficiency andimprove patient satisfaction without theimprove patient satisfaction without theaddition of major resources
o Find ways to do better with the sameo Ensure the ED is a sustainable system
Strategic Alignment
Aligned with Capital Health’s renewedorganizational strategy - Our Promise in Action:
B ild lt f t io Build a culture of customer serviceTransforming the Person-centered Health Care Experience
o Strengthen accountability of employees and PhysiciansTransformational Leadership
o Innovate systems and processes for greater efficiencySustainability
Equipped for Change
• Fall 2013: Stable staffing situation, major free agent i isigning
• Keen new young staff willing to embrace change• Keen, new, young staff willing to embrace change
• Many staff came from other departments across the y pcountry 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 acomprehensive assessment of the system
• This work included: o An environmental scano Process Mappingo Data collectiono Review of ED resource capacityo Team discussions
Analysiso 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 roomComfort 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 teamstood out and became the core focus for the team
“Ensuring the most rapid possible contact with a physician satisfies the g p p p ydesires 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
Weekly mean door to doctor 132.1 minutes 126.7 minutesytimeWeekly mean length of stay 233.6 minutes 197.5 minutes
Weekly 90th percentile 240 2 minutes 217 5 minutesWeekly 90t percentile 240.2 minutes 217.5 minutes
Weekly % <90 minutes 36.5% 39.7%
Team Findings
Low acuity patients have long wait timesy p gimpacted 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 the nurse first modelg
Required Operational Changes to Support The New ModelSupport The New Model
• Role of registration clerk was expanded to direct low acuity
patients directly into the ED
• The flow of the patient’s chart changedThe flow of the patient s chart changed
• The concept of patients being screened by the nurse was
introducedintroduced
• 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• 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 promotes efficiency of care and shortens lengthdesires of ED patients, promotes efficiency of care and shortens length of stay”.
Leading practices in Emergency Department Patient Experience; Ontario Hospital Association (2010/2011)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 contact with a Physician satisfy the desires of the p y ypatient?
• Does rapid contact with a Physician promote efficiency of care and shorten length of stay?g y
Critical to Quality Measures
1. Weekly % of CTAS 4 and CTAS 5 patient going directly to waiting roomroom
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 patients2. Weekly mean Door to Doctor for CTAS 4 and CTAS 5 patientsBased on the core focus of satisfying the desire of rapid access to Physician assessment
3. Weekly 90th percentile door to doctor time for CTAS 4 and CTAS 5 y ppatients
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 44. Weekly % of patients with Door to Doctor time <90 minutes for CTAS 4 and CTAS 5 patients
Aligning performance with a defined standard of care for low acuity ED patients
5. Weekly mean length of stay for CTAS 4 and CTAS 5 patientsy g y pBased on the presumed correlation between rapid contact with Physician and shortened length of stay
Flow Logic
May still take some time to see a Doctor,yHowever:
P ti t i Ph i i t t• Patients in Physician assessment queue supports 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 placetreatment may take place
• In the correct queue; waiting room adds no value to ti t ipatient experience
Intake and Patient Flow
Low Acuity Direct to Waiting Room
Percentage of low acuity Patients Direct to Waiting Room
96.0%
98.0%
Room
92.0%
94.0%
90.0%
92.0%
86.0%
88.0%
Low Acuity Direct to Waiting Room
120.0%
Percentage of Patient Direct to Waiting Room
100.0%
60.0%
80.0%
20 0%
40.0%
y = -0.0018x + 73.4610.0%
20.0%
Weekly Mean Door to Doctor
250 0
CTAS 4 Weekly Mean Door to Doctor Time
200.0
250.0
150.0
0 0481 2105 5
100.0
y = -0.0481x + 2105.5
0.0
50.0
0.0
Weekly Mean Door to Doctor
200
Pre and Post January Weekly Mean Door to Doctor Team
150
200
100
150
y = -0.2203x + 139.39
50
100
y = -0.3077x + 118.250
01 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
90th Percentile Door to Doctor
350
90th Percentile
300
350
200
250
s Ti
tle
y = -0.0487x + 2239.6100
150Axi
s
0
50
1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4
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CTAS 4 Door to Doctor < 90 mins.
80.0%
Door to Doctor Time < 90 Minutes
60.0%
70.0%
40.0%
50.0%
y = 0.0003x - 10.52420.0%
30.0%
0.0%
10.0%
0.0%
CTAS 4 LOS
350
CTAS 4 Weekly Mean LOS
300
200
250
y = -0.0512x + 2335.2100
150
0
50
0
CTQ Statistical Results
Low acuity weekly statistics(door to doc and LOS)
Pre January
Post January
Delta Meansstatistically ( ) y
14th 2013y
14th 2013y
different?
CTAS 4 (mean) 132.1 110.8 21.3 YesCTAS 5 (mean) 126.7 108.3 18.4 Yes( )CTAS 4 (median) 118.8 94.5 24.3 YesCTAS 5 (median) 113.1 93.1 20 YesCTAS 4 90th percentile 240 2 217 5 22 7 YesCTAS 4 90th percentile 240.2 217.5 22.7 YesCTAS 4 90th percentile 228.5 200.6 27.9 YesCTAS 4 % of patients < 90 min 36.5% 48.4% 11.9% YesCTAS 5 % of patients < 90 min 39.7% 49.6% 9.9% YesCTAS 4 LOS 233.6 210.9 22.7 YesCTAS 5 LOS 197.5 180.6 16.9 NoCTAS 5 LOS 197.5 180.6 16.9 No
Two sample t-test at 95% confidence interval used to test results
Post Implementation Survey ResultsResults
Survey Statistical Results
Survey Question Pre mean score
Post mean score
Delta Meansstatistically different?score score 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 3 38 1 01 YI was seen by a doctor in a reasonable amount of time 2.37 3.38 1.01 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 Yesinformed about tests and treatments
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 b t b th t ff
3.39 4.1 0.71 Yesabout by the emergency staff
Throughout my Emergency Department visit (triage, registration, tests, and treatment), my pain level was managed in a timely manner
3.5 3.79 0.29 No
Staff kept me (or family / friends / care giver) informed about the next steps in care
2.88 3.69 0.81 Yes
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 promotes efficiency of care and shortens lengthdesires of ED 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 contact with a Physician satisfy the desires of the p y y
patient?• Does rapid contact with a Physician promote efficiency of care
and shorten length of stay?g y
Continuous Improvement
• Team celebrated success of the work, but i th t thi i k irecognizes that this is a work in 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.”– ED RN
• "The changes in the department have made a huge difference, for patients and morale.“
– ED RNED 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 Ph i i– ED Physician
• “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!”
– Patient Survey Comment
• “This was the fastest time to see a doctor, the doctor was very professional.This was the fastest time to see a doctor, the doctor was very professional. Rate him a 10 out of 10.”
– Patient Survey Comment