How One Hospital Slashed ED Waits
It’s somewhat ironic that patients coming to an emergency department expect to wait for hours on end before being seen by a nurse or physician. They expect to get caught in a bureaucratic maze in which they are asked for the same health information multiple times by multiple people. And they expect to have tests done and redone. For the 110 million emergency department visits in 2004—the most recent data available—patients spent an average of 3.3 hours from check-in to discharge or admittance, according to the Centers for Disease Control and Prevention. “It’s not the level of service we should expect,” says Alan Kent, president and CEO of Meadows Regional Medical Center, Vidalia, Ga. Kent knows that it can be better. In 2005, the average length of stay in Meadows’ ED was 247 minutes, just over four hours. The organization embraced so-called lean management techniques, and in the first quarter of 2007, the average length of stay fell to 139 minutes, a 43 percent decline.
How did Meadows do it? Using grant money from East Georgia College, Meadows turned to the Georgia Institute of Technology’s Enterprise Innovation Institute for guidance. The Georgia Tech team is widely regarded as one of the nation’s leading authorities on the Toyota Production System, also known as lean management. Frank Mewborn, manager of the health care process improvement program at the institute, led the initiative, starting in 2005.
| STEP 1 | STEP 2 | STEP 3 | STEP 4 |
| Training | Value stream mapping | Brainstorming | Develop the project plan |
It’s important to involve all departments that touch the ED. So Meadows CEO Kent selected a team of 20 people to get the initial training, including representatives from admitting, housekeeping, radiology, laboratory—anywhere a bottleneck could occur. “The foundation is breaking out what is waste and what is value,” Mewborn says. “The things that add value are triage, the nurse assessment, the doctor assessment and then the treatment. Things that don’t add value are sitting there waiting, answering the same question five times, being moved from one room to another, having tests redone.” During the full day of training, Mewborn shows people how to look for barriers to work. They also identify workarounds and why those are inefficient. |
Mewborn and the team map out exactly what happens to a patient when he or she walks into the ED, and how long they wait at each station. • Preregistration • Triage • Registration • Nurse assessment • Tests • Physician assessment • The potential for more tests • Treatment • Discharge “We found lots of waste,” Mewborn says. “Watch what happens in an ED. Watch how much time a nurse spends looking for charts or supplies or trying to decide what to do next.” |
How can waste be eliminated? “If the longest wait is between registration and the nurse assessment, that means the nurse is the bottleneck,” Mewborn says. “So we brainstorm on what we can do to take the workload off of them.” The team generated nearly 80 ideas. Each idea is ranked on three criteria: impact, timing (how long it will take to implement) and cost. There’s a 3-point scale—high, medium, low. Typically 15 percent to 25 percent of the ideas are low-cost, short-term and have high impact. These are the no-brainers. Some examples at Meadows include: • A color-coded flag system outside of rooms so physicians and nurses can quickly see a patient’s status • Standardizing supply stations so nurses know where to look for things • Issuing patients red armbands to signify an allergy. “Then you start getting into things that didn’t rank real high in a category and you have to start making decisions and prioritizing,” Mewborn says. |
Meadows whittled its list down to 44 action items. Some are still being worked on. The challenge is moving forward. “We need to feed the fire,” Kent says. “If turnaround time is 120 minutes, can we be at 90 minutes?” To keep staff focused on this—and other projects—Meadows established an employee incentive program. In October, Kent cut checks totaling $90,000 for staff bonuses based on improvements through the first quarter. “Employees understand that each of their jobs is tied to the organization,” he says. |