![]() ![]() The team observed the process during this initial trial and made changes both in real-time and at the Day 5 session. The team developed new front-end processes (described below) and piloted the new system for 8 hours on Kaizen Day 4. Important questions such as patient/family safety questions and learning preferences were moved to later portions of the visit. ![]() Steps removed included questions previously placed in the triage process by other QI efforts but not considered critical to the front-end process. The team met in November 2016 for the Kaizen and spent the first 3 days using Lean methodology 22 to remove redundant and non-value-added steps from the front-end system. Value-stream MAP of original front-end system. With a goal of operational changes in place by January 2017, the team decided to hold a 5-day Kaizen 21 event to expedite system implementation. The team determined that of the average 80-minutes patients spent waiting to see a provider, only 10 minutes was spent in-process, of which <3 minutes was considered value-added to the patient (Fig. The team employed QI and Lean methods to study the current system, including process-mapping of the front-end system and subsequent development of a value-stream map. Starting in June 2016, an expanded inter-professional team including >20 members of ED leadership, physicians, APPs, nurses, EMTs, and registration staff members began meeting to plan further large-scale improvement efforts. The ED Medical Director and Assistant Clinical Nurse Manager formed an ED Operations Committee in June 2015 to help lead the initial PDSA cycles and educate staff. With the support of hospital executive leadership, the ED hired a process improvement specialist to help with these efforts. ![]() The ED leadership team met in early 2015 to discuss improving operational flow. The purpose of this report is to share the change process, specific operational changes implemented, and the resulting impact on patient flow in this tertiary-care pediatric ED. In 2016, the ED leaders, staff, and providers wanted to improve patient flow via a large-scale front-end system redesign. 19, 20Ĭhildren’s Hospital Colorado has seen increased patient volumes and LWBS rates since moving into a new hospital in 2008 (Fig. 12– 18 Most reports of patient flow improvements come from general EDs, where the majority of patients are adults thus, there are few reports of how similar strategies may impact pediatric-focused EDs. 8– 11 A Physician in Triage and other models utilizing non-physician providers can decrease door-to-provider times and decrease left-without-being-seen (LWBS) rates. Strategies employed to improve the front-end processes include the abolishment of traditional nurse-led triage, “split-flow” models that create separate patient streams depending on each individual’s particular care needs, direct-bedding of patients, and placing providers in triage. 8Ī key driver of ED patient flow is its “front-end system,” consisting of all the operational steps that occur before a provider sees the patient. 7 The American Academy of Pediatrics also recognizes this as a particular problem affecting the care of pediatric patients in the ED and in 2015 published a report outlining best practices for patient flow and care for these patients. 2, 5, 6 There is an increased national focus on this important health topic, with the Center for Medicare and Medicaid services identifying multiple operational metrics as key to evaluating the quality of care provided in an ED. 4 Crowding leads to longer wait times to see providers, patient safety concerns, worse outcomes in certain clinical scenarios, and decreased patient satisfaction. 1– 3 Causes of crowding include increased use of EDs, patient boarding in the ED, increased patient complexity, and inefficient ED operations. Patient crowding is a problem facing emergency departments (ED) worldwide. ![]()
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