Value Stream Mapping
As any visual learner knows, sometimes you need to see things to believe them. When St. Luke’s Episcopal Hospital in Houston wanted to revamp its emergency department (ED) processes in order to reduce diversion time, patient length of stay, and left-without-being-seen rates, they decided to use a Lean tool known as Value Stream Mapping. Value stream mapping is a method of diagramming patient or process flow through a given area to identify and eliminate sources of waste and delay. Andrew Eller, RN, BSN, St. Luke’s Episcopal Hospital Ambulatory Surgery Nurse Manager, and former Clinical Educator of the Emergency Department, says value stream mapping was the key to understanding why the hospital’s 29-bed ED was underperforming.
“The CEO of the hospital, David Pate, MD, JD, had received both compliments and complaints from patients, and he wanted to better understand how so many people could be happy while others were so dissatisfied with their patient experience,” Eller recalls. “Upon further examination, we realized our ED practices, processes, and performance were inconsistent. We wanted to ensure our patients were receiving the best patient experience every time, so we developed standardized processes that could be used by everyone providing care.”
Value Stream Mapping
“By creating a value stream map we were able to outline, step by step, the patient’s total experience, from door to discharge,” Eller notes. “We then used this tool to identify bottlenecks, delays, and barriers and create a visual illustration of how patients flow through our ED.”
The value stream mapping process began with a team consisting of emergency department staff, physicians, ancillary support departments (including lab, radiology, patient access services, and information technology) and administrators. “We simply took a blue print of the department and began to identify and diagram the patient throughput process step by step. We timed how long it took patients to go through each step and illustrated the process on a value stream map. For each step, we observed at least ten repetitions. Benchmarks were established by averaging the time per step.”
The ED’s value stream map showed excessive delays in registration, triage, patient placement, physician assessment, and testing results. Armed with this information, the team designed a new ED plan that could be implemented using waste-reduction tools from Lean, a methodology derived from the Toyota Production System.
Rapid Assessment and Disposition
Rapid Assessment and Disposition (RAD) was designed to provide more efficient care to non-emergent patients. This was done by reallocating existing ED space and resources such as treatment rooms, equipment, staff, and providers. Specifically, the registration and triage process were streamlined and an area dedicated to patient screening was created by converting three of the ED’s five critical care rooms into a rapid assessment and holding area. Of these three rooms, two remained exam rooms while the third was turned into an area where patients could be screened and then await test results. According to Eller, this not only created a space for RAD but gave the ED an additional 14 treatment areas.
“The staff worked collaboratively to decrease the amount of time a patient had to wait to see a provider,” says Eller, who was the clinical educator in the ED at the time of RAD’s implementation as well as the ED’s designated Lean champion. He notes that St. Luke’s ED admits 45% of the patients that come through the door — compared with the national average of 12% — due to a large volume of individuals with highly acute, chronic medical conditions and multiple morbidities. “The acuity is so high that less emergent patients kept getting bumped and bumped and bumped,” he says.
Under the new process, all patients arriving at the ED are greeted by a screening nurse, who does an initial assessment using the emergency severity index (ESI). Patients screened as ESI Level-1 and Level-2, are taken immediately to a room for assessment and treatment. Those patients that are screened as ESI Level-5, Level-4, and Level-3 receive a complete assessment in triage and are placed in the RAD area. Patients screened to be treated in RAD include: patients that do not require cardiac monitoring; patients who can be treated with oral medication or limited IM/IV medications; those with vital signs within normal limits; those not requiring a stretcher; and those awaiting testing and or disposition.
The first step in the RAD process is an evaluation and assessment by a nurse and physician together. At that time orders and testing protocols are initiated. Those patients needing further intervention or treatment are sent to a treatment room, while those who do not, are placed in the results waiting area — under the watchful eye of the staff — to await results and complete the registration process. Once the test results are received and reviewed by the physician, patients are either discharged home or admitted.
The Impact
A 2007 comparison of St. Luke’s data with data from the Centers for Disease Control and Prevention identified significant areas for improvement: of the ED’s 32,000 annual visits, 41% of patients were admitted to the hospital after waiting, on average, over 7.5 hours. The hospital was on total diversion 32% of the time, and nearly 8% of the ED’s patients left without being seen.
By 2009, the ED had seen dramatic improvements due to RAD. The average length of stay for high-acuity patients declined by 12% and by 56% for RAD patients. Due to the decreased length of stay and improved throughput, the left without being seen rate decreased from 8% to 1% and the average amount of time spent on diversion declined dramatically.
“Value stream mapping was critical to providing staff with a realistic picture of what our patients were experiencing in our department on a day to day basis and highlighting opportunities for improvement. Using this tool we were able to identify opportunities to improve processes and implement changes that would improve the working environment for employees and the overall patient experience,” Eller says. “The hardest challenge was convincing the ED staff and physicians it would work. Initially they were not in favor of it, but as we kept working and began to see improved results, they quickly came on board with the new processes. Nurses went from routinely having 15 or more patients waiting in the waiting area to having five or less, which took a great amount of pressure off them.”
“The key thing is that people have to think outside of the box,” he adds. “Really engage your staff and let them dream big. Most times the best ideas come from the frontline staff whose ideas are commonly not given a chance.” Data is critical. “Sometimes we go with hunches rather than what data shows,” he says. “Watch the data — it will show you if it’s working or not.”
Andrew Eller, RN, BSN, Nurse Manager, Ambulatory Surgery, St. Luke’s Episcopal Hospital, Houston, Texas
