You may have felt the wait was too long. You may have been asked the same questions over and over again. And you might have noticed there were a lot of people there, some of whom didn’t seem to actually have an emergency.

If you’ve been there, rest assured the emergency personnel were probably sharing your frustration. Although ED’s are typically fast-paced, and the staff tries to treat patients as quickly as possible, inefficient processes can result in a chaotic situation for both patients and staff.

Charleston Area Medical Center (CAMC) is West Virginia’s largest medical center and a Level 1 trauma facility. Since 2003, visits to CAMC’s General Hospital Emergency Department have grown by 5-6 percent annually. This increasing volume, along with a desire to improve patient care and satisfaction, prompted CAMC to hold a Lean Kaizen event designed to streamline the ED.

Planning and Preparation
CAMC’s Six Sigma program began in 2000, but the organization had a long history of process improvement efforts prior to that. In 2005, CAMC added Lean, using the SCORE™ methodology from BMG to jump start the process. After developing a list of potential Lean projects, one of the highest priorities was to reduce treatment initiation lead time for patients visiting the General Hospital ED.

CAMC Black Belt Steve Cunningham says the project goal was to start providing care to patients within 30 minutes after arriving in the ED (an industry standard target). As he explains, there’s something psychological about being moved to a treatment room sooner rather than later. Even if the patient has to wait a bit, or provide additional information after being moved, the patient’s perception is that they are being taken care of more quickly. Of course, the team hoped the process actually would be quicker after making some improvements.

Before beginning the 3-day Run week, or Kaizen event, project team members attended Just-in-Time training to learn the fundamentals of Lean and BMG’s SCORE methodology.

Kaizen Event - Day One
One of the challenges facing the team was the physical limitations of the emergency department – essentially it was landlocked, wedged between the O.R. and radiology, and blocked from expanding outward by a busy street intersection. So, the team had to find other ways to accommodate the growing needs of the ED without expanding the area or even revamping the space. The team started by observing the actual ED process, looking for inefficiencies.

Among the problems that observation identified were significant travel time for registration staff, disconnects in communication between triage and treatment area personnel, and under-utilization of open treatment rooms and beds.

The sequential nature of the process also concerned the team. “Our ED staff was very task-oriented, but not very process-oriented,” admits Cunningham. “Everybody had their roles clarified, but there wasn’t much coordination in the way the process worked.”

This resulted in a fragmented and lengthy patient experience, which the team confirmed with a current value stream map that brought to light several long delays. For instance, the patient wait time between completing registration and being moved to a bed averaged over 17 minutes. The time between the RN’s visit and the doctor’s arrival averaged over 23 minutes.

Instead of singling out these bottlenecks, however, the team concentrated on the flow of the entire process. From patient sign-in to physician orders the average time was 99.6 minutes. But only 24.8 minutes was value-added time, leaving plenty of room for improvement.

Kaizen Event - Day Two
On the second day of the Kaizen event, the team worked on the future state design. They developed two processes — one for treating patients during “normal” conditions when ED beds are available, and one for busy times when all the ED beds fill up and treatment must be initialized in the waiting room or triage area.

Both scenarios featured a shorter registration system to minimize initial paperwork and get the patient into the system quickly. The team proposed that the registration staff gather the rest of the information later, at the patient’s bedside, and then use a hallway computer to complete the process.

The team also proposed creating an “assessment team” consisting of the primary nurse assigned to the patient, plus a physician and an assessment nurse. The team would visit each patient together, reducing the amount of information the patient had to repeat. In addition, the assessment nurse, a position created by the project team, would not have any assigned patients and so would be able to help facilitate care for all patients (e.g., check on lab results, compile x-rays, etc.).

The project team took advantage of a nearby clinical training area to test the proposed process. A few team members volunteered to be “patients” and the others guided them through the steps. After a few tweaks, the team decided it was time for a real world test.

Kaizen Event - Day Three
On the third day, the project team went to the emergency department and briefed the ED staff on the revised procedures. The team then singled out two patients and guided them through the “bed available” scenario. When the ED got busier, they selected another patient and tested the “bed not available” scenario. In both cases, the results were even better than they had hoped. The observed average time from patient sign-in to initiation of care was 6.5 minutes – a 95 percent improvement over the baseline, and way below the project’s 30 minute goal!

The Results
After the Run week, the CAMC project team held a 3-4 day pilot in the ED. As it turned out, the concept of the assessment team had to be modified. “There are so many things going on in the ED,” says Cunningham, “to get the physician, the assessment nurse, and the primary nurse to all stand still at the same time was just going to be next to impossible.”

A more viable alternative was to have the assessment nurse visit the patient bedside with the physician whenever possible. However, if the doctor was not available, in the majority of cases the assessment nurse could assess the patient, discuss findings with the doctor and obtain verbal orders to initiate care. This solution eliminated having to get three busy people in the same place at the same time, while still expediting patient care.

When the hospital was ready to implement the changes, the project team ran a second pilot to make sure everyone was on the same page, and that no other changes were needed. This go round, the average time between patient sign-in and initiation of care hovered around 30 minutes – not as impressive as the 6.5 minutes observed during the event week, but still an improvement over 99.6 minutes.

After implementing the new procedures, patient satisfaction scores have been positive says Marianne Richardson, the Nurse ED Manager (who was also the Kaizen event team leader). In addition, she predicts that the hospital will see a reduction in LWBS (left without being seen) rates because patients are being taken care of so quickly. Plus, the changes move CAMC closer to one of its strategic goals – to reduce by 50 percent the number of patients with an ED length of stay longer than four hours.

Although Richardson reports that the new process met more resistance from staff than she thought it would, she did what any good manager would do. She talked to her people. In the end, they worked through the issues. “We’ve modified the new process to meet the needs of the staff and the goals of the hospital. We were able to compromise.