Lean Healthcare Drives Community Hospital ER Performance

By Ken Congdon, Editor In Chief, Health IT Outcomes

A new patient documentation solution was central to a lean movement in the ER of Good Samaritan Hospital that decreased average door-to-doctor times and length of stay, while reducing staff overtime.

A lot of focus is being given today to how sophisticated health IT systems are benefiting hospitals, but sometimes it’s the little things that make the biggest impact. With so many community hospitals still ill-equipped from a financial, human resource, and IT infrastructure perspective to implement full-scale technology systems, it’s good to know that simple process changes can go a long way to maximizing efficiencies. In fact, the first step in any technology deployment should be to make sure that your existing manual processes are as streamlined and effective as possible — this is where lean methodologies such as Six Sigma and Kaizen can produce lasting results. Good Samaritan Hospital, a 287-bed Level II trauma center in Kearney, NE, can attest to the benefits of going lean. This hospital recently embarked on a lean movement in its ER that has significantly enhanced many of the department’s key metrics, including door-to-doctor times, length of stay times, staff overtime, and patient satisfaction scores.

STORAGE, ASSESSMENT, AND DOCUMENTATION PROBLEMS TARGETED
Good Samaritan's ER staff identified several key problem areas that created departmental inefficiencies when it came to patient flow and patient care. For example, the ER had its equipment and supplies scattered in various locations throughout the facility, forcing nurses to travel from room to room during the course of a shift to obtain the medical provisions needed, which prolonged patient care. "We actually asked our nurses to wear pedometers and discovered that they were walking between 8 and 11 miles per shift," says Diane Donovan-Watley, RN, CEN at Good Samaritan Hospital.

Furthermore, the secure medication dispensing carts used to store the drugs administered to patients was located in the middle of the nurses' station. This location was a hub of activity — a far cry from the quiet, undisturbed location recommended by JCAHO (Joint Commission on Accreditation of Healthcare Organizations), ASHP (American Society of Health System Pharmacists), and others to ensure medication administration safety.

More patient flow inefficiencies were linked to the ER patient assessment processes at Good Samaritan. Like many hospitals, Good Samaritan's ER nurses would conduct an initial assessment of a patient, and an ER physician would conduct a follow-up assessment.

"Often, the physician would ask the exact same questions the patient had already answered for the nurse," says Donovan-Watley. "Not only was this a time-consuming duplication of effort, but also it sometimes had a negative influence on the patient experience."

However, without question, the most profound inhibitor of optimal ER patient flow at Good Samaritan Hospital was the department's patient documentation system. "In the past, we developed the forms our nurses and physicians used to record patient complaints, histories, diagnoses, and treatments in-house," says Donovan-Watley. "These forms left a lot of room for individual interpretation and were not compliant with regulatory demands. Filling out these forms was a manual, time-intensive process. Furthermore, the data contained on each form was often inconsistent or lacked specificity. This sometimes led to coding inaccuracies that would lead to claim issues."

EMPOWER FRONT LINE EMPLOYEES WITH LEAN INITIATIVE
Good Samaritan's ER staff wasn't just tasked with identifying these problem areas — they were also empowered to suggest and implement the solutions. The hospital initially hired consultants to provide the ER staff with a two- to three-day training course on lean methodologies. After that, it was up to members of the ER staff to implement these strategies and sustain them.

"A cultural change of this magnitude can't be a mandate handed down by the CEO," says Donovan- Watley. "It needs to be ingrained in your personnel in order to sustain results. Your frontline employees must be given the liberty to execute on their own ideas. This will create the buy-in and adherence necessary for the initiative to be successful."

In an effort to make its equipment and supply processes more lean, Good Samaritan's ER staff made the decision to consolidate these materials in a central location. They carved out a single dedicated storage area and even reconfigured some of the storage cabinets.

"Many of our storage cabinets have glass doors, so that you can see the items contained inside," says Donovon-Watley. "However, we were obstructing our view of these items with a paper inventory list that we would tape to these glass doors. We started printing these inventory lists on clear plastic sheets so we could see through them and into the cabinets. Believe it or not, this made a noticeable improvement in our ability to quickly locate and restock supplies."

It was also decided that the new storage location would be a quiet area separate from the nurses' station. This provided an ideal space for the ER's medication dispensing cabinets. All in all, the ER's new central supply room helped reduce the miles logged by nurses from 8 to 11 miles per shift to 3 to 6 miles per shift, allowing these caregivers to dedicate more time to patients and address patient needs faster.

The ER staff also applied lean methodologies to its patient assessment processes. Rather than having nurses and physicians conduct separate assessments, the decision was made to start performing dual assessments in the ER. Now physicians and nurses meet together with the patient to ask questions and capture patient vitals and notes. This change has eliminated the duplication of effort that previously existed and has shortened the time required to complete assessments.

"Our dual assessment process has been completely seamless," says Donovan-Watley. "It ensures our nurses and doctors are on the same page and is more convenient for the patient. It's actually reached the point where our doctors and nurses can read each other's minds. They can walk out of the assessment together and immediately start writing orders."

TEMPLATE-BASED DOCUMENTATION PROVIDES CONSISTENCY
When it came to improving its patient documentation processes, Good Samaritan sought standardization. Inevitably, several vendors tried to get the hospital to adopt their e-forms and electronic charting offerings. However, with most of its systems still in paper form, the ER knew it wasn't yet equipped to get maximum effectiveness out of an electronic documentation solution. Instead, Good Samaritan found the lean paper-based documentation solution it was looking for in T Sheets by T-System, Inc.

T Sheets is a paper template system that helps clinicians chart up to 150 patient complaints (covering 95% of ER cases) in a visual way. Each form is focused on the problem the patient presents with (e.g. chest pain, motor vehicle trauma, etc.) and is specifically designed to capture information related to that problem in a standardized way. Using these forms, clinicians can quickly document patient encounters using a series of circles and/or backslashes, eliminating the need for extensive free text and dictation. T Sheets also comply with federal regulations and industry best practices while providing consistency in procedure coding.

"We immediately saw an increase in department revenue upon using the paper template system," says Donovan-Watley. "This was largely a result of fewer coding inaccuracies that ensured we were consistently reimbursed correctly for the care we provided. Furthermore, we've seen a significant decrease in nursing overtime related to charting. Since implementing the solution in 2010, we've reduced our overtime expenses by more than $12,000 per year."

Collectively, Good Samaritan's lean efforts have had a major impact on many of the ER's core metrics. For example, average door-to-doctor time in the ER has been reduced from 20 minutes to 12 to 15 minutes. Similarly, the average length of stay for patients treated and admitted, and treated and released, has been reduced by 15 to 17 minutes.

"Our average length of stay in the ER is under 90 minutes consistently," says Donovan-Watley. "Any emergency department in the U.S. would die to have these metrics. Plus, all of our HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] patient satisfaction survey scores have gone up since our lean implementation."