new zealand eastern health: improving ed to ward transfer lean team members michael butler

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New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

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Page 1: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

New Zealand

Eastern Health: Improving ED to Ward Transfer

Lean Team Members

Michael Butler

Page 2: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Overall Process Being Mapped

After consultation with the Hospital’s Admission & Discharge Manager, the initial plan was to map the journey of a medical patient from admission to the Emergency Department to transfer to Ward 2 East. This process was selected for a number of reasons, including:

Ongoing problem of meeting our DHS HDM access target for ‘No. of Patients with LOS in ED >24 hours’, which appeared to correlate with patients requiring admission to a medical bed

The ED had previous Lean experience, including undertaking 5S and VSM – associated with ‘InformED’ funding

Low Nursing Staff morale in 2 East Opportunity to link this with other improvement activities occurring in 2 East

and to impart Lean Thinking to the nursing staff of the ward

Following completion of the current state VSM for this process, in consultation with 2E NUM & ANUM it was decided to narrow the project focus to a process related to the admission from ED to 2E, thus the following.

Page 3: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Project Aim & Plan

Project aim:Reduce bed preparation time to 30 min in Ward 2 East(From bed vacated to next admission from ED)

Project Plan:VSM, presentation to ward staff, consult’n with NUM, Nurses & WSS Identify waste / problem areas

Inefficient work areas – pan room, treatment room, work stations, etc.Non-standardised work – nurses & WSS have varying systems of identifying &

notifying one another of a bed to be cleaned / once a bed has been cleaned.

Key Stakeholders Medical patients, 2E NUM / ANUMs / staff, Bed Mgr, ED staff, WSS staff,

Hospital executive team

Page 4: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Current State Value Stream MapMedical Patient

ED Med Orderly Consultant

Ward 2EPage / Call back Callvia clerk

Call / Call back

PMI Pathology Radiology ED HMO Bed Mgr

Page / Call back via clerk Page / Call back

via clerk

Emerg. Resp Triage Registration Nursing Ax Medical Ax Radiol Proc Medical R/V Medical R/V Transfer toAmbulance ED ED ED ED Radiology ED ED Ward 2EParamedic Triage RN ED Clerk Primary RN HMO Radiographer HMO HMO Orderly

ED Consult. Escort RN

Obs Brief Hx = Pt details = Undress pt = Hx = Pos'n pt = R/V XR = Path. results Orderly remains with ptBrief Hx Obs = PMI search = Obs = Ax = Obtain CXR = Ongoing Rx Dx = H'over by ED RN to 2E Charge RNAx Categorise = Hx = Order Ix = Call to admit consEmerg. Rx Document = ECG, bl'ds = Decis'n to admitTrans to ED Insert IV = Ongoing Rx

3 min 10 min 10 min 5 min 15 min 15 min 75 min 70 min ProductionLead Time = 203 min

5 min 5 min 20 min 30 min 15 min 5 min 10 m 5 m ProcessingAwait orderly Inc. trans Await Path Notify Bed Mgr Time = 95 min& trans to back to ED Clerk page HMO Neg. transferRadiology Assumes bed available

Await orderly & escort RNOngoing RxTrans to ward

WWWWWW W

Page 5: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Bed Prep Value Stream Map – Future State:

2E Bed(Next Med Pt from ED)

EDNUM / ANUM

ISS Ward Bed Allocation Bed Support Whiteboard Co-ordinator

Page / Call back Page / Call back

Bed Vacated Contact WS Collect Clean'g Bed Cleaned Confirm Bed Clean Advise Bed available Handover Transfer Pt2E Pt Rm Nurse Station Pan Rm 2E Pt Rm 2E Ns Station 2E Ns Station 2E Ns Station 2E Pt Rm

Primary RN Charge RN WSS WSS WSS Charge RN Charge RN Primary RNCharge RN ED RN EDA

C'nfirm bed vacated Page or walk to find Collect items Bed cleaned WSS wipes off 'TBCP' Page Bed Handover Transfer pt to bedIdentify bed to be cleaned Bed made from whiteboard Co-ordinator EDA with pt Prioritise work load Time neg for pt trans

15 min 5 min 0.5 min 1 min 30 min 35 min 1 min ProductionLead Time = 87.5 min

1 min 1 min 1 min 10 min 0.5 min 2 min 5 min 3 min ProcessingDelay if WS Delay if Charge RN Inc pt transport Time = 23.5 mincalls back is not made aware from ED to 2E

Total time = 111 min

WWWWWW W

Non-standardised Work Develop consistent RN & WSS roles inc.

WSS workload prioritisation & notification

Plan / allow for ED admission using

Trendcare (develop pull system)

Various WasteUse 5S to improve efficiency of

work areas in 2E

Non-standardised WorkStandardise notifying of clean bed

Page 6: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Kaizen Blitz Actions:

Identify ward admission takt time – Source: Trend Care Takt time (identified using 12 months of admission data) = 3.327 admissions per day Takt time for each day of week also identified

‘Follow’ bed at different times in day Progress –3 beds ‘followed’ & mapped during morning shifts, to be followed by mapping during pm shift

Further define p.r.n. by using ‘problem is/is not’

Collect data – bed vacated & admission to ward times Pre-implementation data collection commenced

5S to improve efficiency in identified ward areas Project team formed and work commenced Ward areas identified and prioritised Information on 5S tool provided and 5S expertise sort from ED Logistics Co-ordinator

Standardise work / roles of WSS and nursing staff in relation to bed preparation / cleaning – written guidelines Project team formed and bed mapping completed Issues as previously identified Additional issues identified, including inconsistent use of Transit Lounge!

Page 7: New Zealand Eastern Health: Improving ED to Ward Transfer Lean Team Members Michael Butler

Next Steps:

Project handed over to Ward 2 East (December 2006)

EH ED Patient Flow Committee formed, including 4 Angliss reps Purpose - ????? Angliss data presented so far has included:

7.3% growth in patients requiring admission to a ward from ED comparing 2005/06 with 2006/07(July to Dec)

Top 10 Diagnosis for LOS >24hrs - audit of pt records of top 3 conditions (UTI, Lobar Pneumonia and CHF) is being conducted to determine reason for delay and if alternatives means of managing pt

Time of Arrival at ED for LOS >24hrs (EH data) Majority of pts with LOS>24hrs arrive between 1000 and 1600 Other data - 1800 to 2200 there are more bed requests than separations, 1000 to 1800 there are more separations

than bed requests Day of the Week ED presentations for LOS >24hrs (EH data)

Data showed a significant increase of 24hr LOS on Sundays, with Friday at 7% and Sundays at 25%. Separations were reversed showing 8% on a Sunday and 17.3% on a Friday

Average time for ‘Available to transfer from ED to Ward’ Varied between 42 - 64 min, sometimes waiting up to 149 min.

Plan to develop Angliss ED Patient Flow Committee, To implement improvements based on EH ED Pt Flow findings / data Membership to inc. IP medical beds (2E) reps To use Lean thinking as the improvement methodology