HIMSS: Process improvement starts in the ED
ORLANDO, Fla.--The changing healthcare landscape has driven the George Washington Hospital to invest time, effort and energy in ED processes that had been neglected, said Neal Sikka, MD, director of emergency medicine at the George Washington University Medical Faculty Associates in Washington, D.C. Access to data also spurred improvement, said Sikka, speaking at HIMSS11 conference last week.
“Before we implemented our EMR, we had no data. We had a general sense of what was going on, but we had no good information,” he said. The hospital faced increasing wait times in the ED, an area of care that is integral. The provider sees about 71,000 patients a year, is the STEMI-receiving site and 24-hour cath lab for the city, and is a comprehensive stroke center.
Implementation of an EMR in the ED was “a catalyst for culture change,” Sikka said. The hospital tried to make sure physicians adopted the EMR as a record for all processes and use it for physician and nurse documentation as well as for computerized physician order entry (CPOE). “Now that we have all these data available, we’re trying to significantly improve our processes,” he said.
All process improvement initiatives leverage data from the EMR. Each includes a process along with considerations of potential staffing and downstream hospital changes.
When the team launched its effort to improve its greet-to-triage time, for example, a personnel shift produced results. Initially, the greeter at the ED door was a staff member from the registration department who used protocol to select the sickest patients and expedite their care. “We were relying on a non-clinical person; we felt that was not good on a lot of levels,” he said. The team added an ED technician to conduct initial triage, and a quick registration into the EMR to find out what was going on with the patient.
Processes aren’t the only thing to get an overhaul: “We redesigned our whole front end … the ED didn’t meet our workflow requirements, so two new ED triage rooms were added.”
Sikka’s team noticed that the re-arrival rate really started to spike around 9:00 a.m. “When we extended triage to 11:00 a.m., we were able to meet the demand—which can be 16 to 17 patients arriving per hour,” he said. “We also built in flexibility to move triage nurses as needed [and] designed a number of courses that triage nurses could implement based on chief complaints. We added a second ED technician to use our new space to do that kind of processing.”
The results? ED wait times have dropped from 20 minutes prior to EMR implementation to about eight minutes as of December 2010, he said.
“These are sustainable changes. The hospital has also moved to using internal and external multidisciplinary teams. We outline, detail and segment process [because] everyone has a different point of view and thinks it happens in a different way. We try to make sure we include labs, radiology, nursing staff and physicians in how to map out a process.”
Looking ahead, the hospital is investigating why there’s a much higher admission rate based on the physician’s years in practice, he said
“Before we implemented our EMR, we had no data. We had a general sense of what was going on, but we had no good information,” he said. The hospital faced increasing wait times in the ED, an area of care that is integral. The provider sees about 71,000 patients a year, is the STEMI-receiving site and 24-hour cath lab for the city, and is a comprehensive stroke center.
Implementation of an EMR in the ED was “a catalyst for culture change,” Sikka said. The hospital tried to make sure physicians adopted the EMR as a record for all processes and use it for physician and nurse documentation as well as for computerized physician order entry (CPOE). “Now that we have all these data available, we’re trying to significantly improve our processes,” he said.
All process improvement initiatives leverage data from the EMR. Each includes a process along with considerations of potential staffing and downstream hospital changes.
When the team launched its effort to improve its greet-to-triage time, for example, a personnel shift produced results. Initially, the greeter at the ED door was a staff member from the registration department who used protocol to select the sickest patients and expedite their care. “We were relying on a non-clinical person; we felt that was not good on a lot of levels,” he said. The team added an ED technician to conduct initial triage, and a quick registration into the EMR to find out what was going on with the patient.
Processes aren’t the only thing to get an overhaul: “We redesigned our whole front end … the ED didn’t meet our workflow requirements, so two new ED triage rooms were added.”
Sikka’s team noticed that the re-arrival rate really started to spike around 9:00 a.m. “When we extended triage to 11:00 a.m., we were able to meet the demand—which can be 16 to 17 patients arriving per hour,” he said. “We also built in flexibility to move triage nurses as needed [and] designed a number of courses that triage nurses could implement based on chief complaints. We added a second ED technician to use our new space to do that kind of processing.”
The results? ED wait times have dropped from 20 minutes prior to EMR implementation to about eight minutes as of December 2010, he said.
“These are sustainable changes. The hospital has also moved to using internal and external multidisciplinary teams. We outline, detail and segment process [because] everyone has a different point of view and thinks it happens in a different way. We try to make sure we include labs, radiology, nursing staff and physicians in how to map out a process.”
Looking ahead, the hospital is investigating why there’s a much higher admission rate based on the physician’s years in practice, he said