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Care Initiation Area yields dramatic results
In February 2008, 12% of the patients who presented to the emergency department 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, for helping 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 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.