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Care Initiation Area yields dramatic results
In February 2008, 12% of the patients who presented to the ED at Gaston Memorial Hospital in Gastonia, NC, left without being treated. By the end of January 2009, that figure had dropped to 1.3%. In that same time period, hours on diversion dropped from 107 to zero, and the average turnaround time fell from 247 minutes to 184 minutes, even though even more patients were being seen (7,677 vs. 7,810.) Press Ganey patient satisfaction scores for the ED's arrival section jumped from the 68th percentile to the 99th percentile.
How could such dramatic improvements be made in such a short time? The ED team credits the Kaizen (Japanese for "continuous improvement") methodology, pioneered by Toyota, that helped it identify inefficiencies, and the introduction of a new Care Initiation Area (CIA) and a physician in triage.
"We decided we needed a care initiation area because we were redesigning processes," explains Kathleen Besson, RN, BSN, MBA, NEA, BC, director of emergency services, who notes that the triage area had been identified as a bottleneck.
"In looking at ways to improve our processes, we wondered if there was an opportunity to use space not being utilized any more and turn it into the CIA," Besson says. "We used simulation software we had here in the building to analyze arrival patterns, decide peak arrival times by the hour, and patient disposition, so we could estimate how many patient spaces we needed in the CIA so patients could come right there in instead of the waiting room." The creation of the CIA, including equipment, cost about $800, she says.
The new process works like this:
Sonya Carver, RN, the ED's clinical manager, says, "In Kaizen, you have your current state, and you have the future state you need to move to. You map out to the tiniest detail exactly what happens with the patient, even to the point of saying, 'The patient walks in the front door.'"
The reason for examining the processes in such detail "is that you can very easily see if there's something that is repetitive and ask yourself why you do that — very minute details you do not think about day by day," she says.
For more information on Kaizen methodology and improving ED flow, contact:
A definition and discussion of Kaizen methodology, along with an illustrative diagram, may be found at www.12manage.com/methods_kaizen.html.
A guide to Kaizen methodology is available at fac.swic.edu/turnerke/Kazien-Guide.pdf.
Kaizen methodology means rapid changes
While the Kaizen methodology, developed by Toyota, involves examining processes in minute detail, it ironically can lead to rapid improvement in ED processes, says Sonya Carver, RN, clinical manager/days for the ED at Gaston Memorial Hospital in Gastonia, NC.
"In one instance, we had a one-day meeting and then did that work product immediately," she says.
Kaizen already had been adopted by the facility to be used for process improvement when the ED set out to improve its triage process, Carver says. "We looked at what was wasteful in our triage design — for example, serial processes as opposed to parallel processes — and developed the methodology that triage is a process and not a place," she explains. With Kaizen methodology, the focus is on the customer, which in an ED can be the staff or the patient, Carver says, "so, it can be used to improve staff work flow so you work smarter and not harder," she explains. "If you can do more with less, like walking fewer steps to a piece of equipment, you eliminate waste and improve quality."
Carver was trained in Kaizen by the hospital's organizational improvement department. Kathleen Besson, RN, BSN, MBA, NEA, BC, director of emergency services, says, "You learn how to lead a group through a Kaizen event and also how to complete documentation so you can come out and have data — before and after, what you have gained — and actually put a dollar or time- saving figure to it. It's a very data-driven, deliberative process, and every project goes through the same steps."
'A two-meeting process'
The facilitator has to make sure they have the right people on the team, then assess the process, establish goals, work through each step, and see what the best opportunities for improvement are, Besson says. "When you come out of the meetings, you implement the changes fairly quickly. It doesn't take months or meetings regurgitating the same things over and over," Besson says. "At most, it's a two-meeting process."
Jodie Cook, RN, ED clinical manager /nights/weekends, who took the lead in staff education, says, "We educated the staff through staff meetings and e-mails, and informed them of the process and what everyone's responsibilities would be. We had a book in the CIA [the Care Initiation Area, one of the Kaizen solutions] describing the new process, and a place in the unit where staff could put suggestions and comments." In addition, she says, the leadership team would meet and debrief after each Monday and Tuesday to see how things were going. "We talked with the charge nurses to see what worked and what didn't," she notes.
Don't hide your light, share success with board
Many EDs have success stories to tell, but how many have told them directly to the hospital board? That's exactly what the ED team at Gaston Memorial Hospital in Gastonia, NC, did, and what a story it was. Using Kaizen methodology, they racked up impressive results in patients who presented to the ED who left without being treated, hours on diversion, turnaround time, and patient satisfaction.
The quality of the presentation did justice to the ED's accomplishments. Not only was there a full-blown computerized slide presentation outlining their goals, implementation, and results, but the presentation was made by several key members of the ED team. "I moved my board meeting to the auditorium so all the staff could come," says Wayne Shovelin, the hospital CEO. "They had about 15 people, including half a dozen ED physicians, which spoke volumes about our culture."
Kathleen Besson, RN, BSN, MBA, NEA, BC, director of emergency services, says, "From my perspective, I had been called to present to the board along with our medical director several times, but I felt pretty uncomfortable because I was not the only person creating the improvement. I told the board I wished they could hear from the staff."
It's important for the board to "meet the people who do great work," and it's also important for ED staff to see the board and the people who are expecting so much from them, Besson says. "The board is just a scary bunch of people nobody knows," she notes. "It was important for the board to understand all the effort that went into the initiative and for the staff to receive recognition."
Besson created the slides, and then each presenting staff member took responsibility for the areas they had championed and knew very closely. "Preparation did not take all that long because we had been using a lot of the data elements all along," she explains.
Jodie Cook, RN, ED clinical manager, who took the lead in staff education, says, "We were all nervous wrecks going in, but when we were done, every single person was so glad, so proud to hear the presentation, to experience the response and talk to board members one on one. When we put the whole package together, you could see what we all had done as a team. The staff members that had come and listened were just amazed."
So was the board, says Besson. "One board member actually had tears in his eyes," she recalls. "Last week, the same board member asked me how to get the word out to the community about all the things we were doing in the ED."
Besson said that wasn't necessary, based on the jump in patient satisfaction rates. "We had all those patients who had the opportunity to see what we do here, and that's the best marketing you can do," she says.
For more information on ED board presentations, contact: