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Case Study: Change Begets Change, Building Capacity at Christiana Care Health System
In 2008, Christiana Care Health System (Newark DE) embarked on a multi-phased odyssey of change. With a 2.5-hour average length of stay for the fast track area, they received a mandate from hospital administration to improve efficiency. About that time, they received a visit from an ED physician looking to learn about their work flow process and operations. On that visit, Dr. Jody Crane* of Mary Washington Hospital (Fredericksburg VA) sparked their interest in LEAN methodology. After studying up on LEAN, they resolved to become expert in implementing a customer-focused management philosophy that aims for "No waste, no waiting, zero harm."Phase 1: Super Track (ESI Level 4 and 5)
Christiana first tackled th
eir fast track process for Emergency Severity Index (ESI) Level 4 and 5 patients. By bringing different points in a patient’s visit closer together, fast track became Super Track (ST). Diagrams were developed to illustrate how staff moved through their day and process flow mapping exposed weak points such as excess movement and over-processing. With this data, Christiana sought to: reduce batching of patients; execute actions in parallel or synchronous flow; and decrease the number of hand-offs. Patient rooms were moved closer to triage, the number of rooms was cut to two, and each room was staffed by a team comprised of a PA, a nurse and a technician. A new questionnaire was designed to quickly winnow out patients not appropriate for ST, and the simultaneous execution of assessment, patient history and physical exam was implemented. Orders for imaging and labs are completed in the room, and the technician ensures that the rooms are always in use.
eir fast track process for Emergency Severity Index (ESI) Level 4 and 5 patients. By bringing different points in a patient’s visit closer together, fast track became Super Track (ST). Diagrams were developed to illustrate how staff moved through their day and process flow mapping exposed weak points such as excess movement and over-processing. With this data, Christiana sought to: reduce batching of patients; execute actions in parallel or synchronous flow; and decrease the number of hand-offs. Patient rooms were moved closer to triage, the number of rooms was cut to two, and each room was staffed by a team comprised of a PA, a nurse and a technician. A new questionnaire was designed to quickly winnow out patients not appropriate for ST, and the simultaneous execution of assessment, patient history and physical exam was implemented. Orders for imaging and labs are completed in the room, and the technician ensures that the rooms are always in use.Phase 2: Synchronized Provider Evaluation and Efficient Disposition (ESI Level 3)
With ST in place, a large number of ESI Level 3 patients experiencing long wait times at triage were exposed. The Synchronized Provider Evaluation and Efficient Disposition (SPEED) team consists of one attending physician, one PA, one resident (partial coverage), six RNs, two technicians and a clerk. The team’s charge is to get patients in and out of the assessment room within 40 minutes. To avoid over-processing: the patient is assessed by both a physician and an RN to decrease hand-off time; intramuscular and oral medications are used when possible; imaging studies are ordered as needed . The technician ensures that all rooms remain full, assists with testing, and transport patients.
Phase 3: Synchronized Healthcare Approach and Redesign Process (ESI Level 2)
While SPEED 
moved ESI 4s, 5s and low 3s along more efficiently, Level 2s and high 3s were building up at triage. Under the Synchronized Healthcare Approach and Redesign Process (SHARP), patients are seen by one of two teams each consisting of two RNs and one technician; an attending physician, PA and a clerk float between the teams. Dual synchronous assessment is performed where one provider assesses the patient while another starts the work up. Clerks post patients for admission, monitor lab results inpatient bed status, and communicate follow-up orders. In synchronous discharge, a provider discharges a patient with an RN or technician present so that patient education can occur simultaneously.
moved ESI 4s, 5s and low 3s along more efficiently, Level 2s and high 3s were building up at triage. Under the Synchronized Healthcare Approach and Redesign Process (SHARP), patients are seen by one of two teams each consisting of two RNs and one technician; an attending physician, PA and a clerk float between the teams. Dual synchronous assessment is performed where one provider assesses the patient while another starts the work up. Clerks post patients for admission, monitor lab results inpatient bed status, and communicate follow-up orders. In synchronous discharge, a provider discharges a patient with an RN or technician present so that patient education can occur simultaneously.“Doing things concurrently eliminates the time it used to take to complete three tasks,” says Karen Toulson, RN, MSN, CEN, NE-BC, Nurse Manager.
Phase 4: Triage Assessment and Redesign Team
“Even after implementing these programs, we still felt the need to improve overall LOS,” says Dr. Heather Farley, MD, FACEP, Assistant Chair, Department of Emergency Medicine.
The Triage Assessment and Redesign Team (TART) used queuing models to coordinate triage.. When a nurse and clerk performed their intake duties together, delays were built into the system because a clerk’s duties are more time-consuming. Now one nurse is paired with two clerks, making it easier to implement standard work procedures.
“One TART intervention was a huge cultural shift for us. ‘Pull ‘til full,’ also known as direct bedding, means that when we have an open room, we immediately place a patient in it and bypass the full triage process,” says Dr. Farley.
TART has met resistance from staff. “Triage nurses realized that their workload was lessened, but core nurses were uncomfortable getting patients who had not had full assessments. Physicians were confronted with full chart racks showing how much work was yet to be done – which is not necessarily a bad thing,” says Dr. Farley.
Begun in April 2011, results are not yet in, but there has been a decrease in door-to-room and door-to-doctor times, and TART is gaining acceptance among staff.
Sustaining Results
“You cannot assume that the process is going to continue to run as you designed it. It’s too easy for people to slide back into the old way of doing things, so it’s important to monitor metrics for each process,” says Dr. Farley.
ED leadership now receives daily metrics, including a graph of Super Track LOS statistics over the course of the day. Throughout each day, staff keep an eye on a computer displaying how long each Super Track patient has been in the ED. “The display helps motivate staff to get patients out in under an hour,” says Dr. Farley.
The Take Away
Three elements common to each Christiana ED intervention improve efficiency and could be implemented in institutions of any size:
(1) Patient segmentation – Assign patients to the appropriate ESI group and manage each group according to their particular needs;
(2) Synchronous work – Where appropriate, do more than one thing at a time;
(3) Standardized work – Minimize variability by executing every task in the same way every time.
Jesse Moncrief, Christiana’s Senior Operational Excellence Consultant, advises EDs to start any process redesign with the patient’s need at the center. Rapid-cycle testing is a quick way to try new ideas, and just-in-time training on new processes brings about change faster. “It’s okay not to hit the ball out of the ball park on the first try,” says Moncrief.
While there was no need to garner buy-in from hospital administration, Ms. Toulson emphasizes that change was brought about through the intimate involvement of the staff. They developed and tested everything, and weren’t completely engaged until they got the “What’s in it for me?” question answered. “Following change theory, we wanted staff to figure out for themselves the ‘burning platform’ [the things that must change in order to ensure an organization’s survival]. We wanted them to have that huge ‘Aha!’ moment. Once they saw how each new processes affected their ability to care for patients, buy-in was automatic.”
ED leadership talked up the message of change and made resources available. “While there were some costs for overtime pay, implementation costs were never really put to paper. Money was not an issue because we knew we would prove our point in the end,” says Toulson.
Of the future, Dr. Farley says they will take aim at streamlining care for their sickest patients in the acute care area.
For more information about Christiana Care Healthy System, check out the Urgent Matters Webinar Rapid Intake and Patient Segmentation: Listen to a Recording Download The Slides
*Dr. Jody Crane was featured in a past Urgent Matters webinar - Evaluation and Management of ESI Level 3 Patients, December 2009 Listen to a Recording Download The Slides and Ms. Toulson recommends a recent book of his – The Definitive Guide to Emergency Department Operational Improvement:. Christiana has deployed many of the tools and concepts described in the book.
Heather L. Farley, MD, FACP, Assistant Chair, Department of Emergency Medicine, Christiana Care Health System
Karen Toulson, RN, MSN, CEN, NE-BC, Emergency Department Nurse Manager, Christiana Care Health System
Jason Deal, MBA, Emergency Care Technician, Christiana Care Health System
Jesse Moncrief, Senior Operational Excellence Consultant, Christiana Care Health System
